Category: Expert

Letting the Patient Matter: Some Thoughts on Irvin Yalom’s View of the Therapeutic Relationship

Posted on by Psychotherapy.net Team

In his recent book The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, psychiatrist and writer Irvin Yalom recalls a poignant encounter with one of his cancer patients. The woman is embarrassed by her hair loss after chemotherapy, and during one of her therapy sessions, she reveals that she would like a sign from Yalom that her baldness does not repulse him. Yalom, who has always admired this patient for the intelligence that illuminates her features, tells her he's not repulsed at all. In fact, he asks if he can act on his impulse to run his fingers through the lovely gray strands of hair remaining on her head. The result is a warm, intimate moment that is cathartic for both.

Such moments, related in his latest book, The Gift of Therapy, serve as vivid arguments for breaking down the walls that separate patient and therapist. Directed to a new generation of therapists and their patients, Yalom is a keen advocate for unmasking the therapist. One of the main reasons that patients fall into despair is that they are unable to sustain gratifying relationships. According to Yalom, therapy is their opportunity to establish a healthy give-and-take with an empathetic counselor; one who is not afraid to show his or her own vulnerabilities.

Opening the Secret Door

A professor emeritus of psychiatry at Stanford University and the author of several widely read books and novels on psychotherapy—including the best-selling therapeutic memoir Love's Executioner and various classic textbooks on group psychotherapy and existential psychotherapy—Yalom's insight into this world throws open the secret door to therapy, both for counselors and the patients who visit them.

What we see behind Yalom's door is a far cry from the stereotype of a therapist. From comic strips to Hollywood features, the analyst is often portrayed seated behind a desk or a notebook, literally out of reach and out of sight of the person being analyzed. “As patients, we perceive that person sitting across from us as a powerful and impenetrable figure, yet we're expected to reveal ourselves up to their scrutiny.” Within the charged atmosphere of the 50-minute therapeutic hour, our psyches are exposed, while the therapist maintains an enigmatic mask.

This may be the traditional model of psychoanalysis, but Yalom challenges it as ineffective and ultimately unhealthy. Real treatment, he says, requires an intimacy between therapist and patient that is born from a solid bond of trust. After all, a patient regularly entrusts a therapist with intimate revelations, so the therapist must be able to respond with true spontaneous empathy rather than stock therapeutic phrases. Nor does empathy evolve in a vacuum. "Friendship between therapist and patient is a necessary condition in the process of therapy," says Yalom, and he encourages the therapist to "”let the patient know that he or she matters to you.”"

When a Patient Spells Trouble

Sometimes letting the patient matter can be a challenge. In his book Love's Executioner, Yalom describes an incident with an Argentine patient who is in the last stages of incurable lymphoma. Because "Carlos" was isolated and depressed, Yalom sent him to a therapy group led by a female colleague, thinking that Carlos might form some personal connections to help him through the challenges of his last months of life. Instead, Carlos' obsession with the female patients alienated everyone in the group. After several of the women brought up their painful experiences with rape, Carlos voyeuristically interrogated them about intimate details and then declared the assaults "no big deal." Furious, the therapist asked Carlos to leave the group.

Although repelled by Carlos' behavior, Yalom persuaded the group leader to let him work with him to see whether he might be able to change his attitude. Carlos defended his prurient interrogations to Yalom, leering that, "All men are turned on by rape," and "If rape were legal, I'd do it . . . once in a while." Sitting in silence for a few minutes, Yalom wondered whether Carlos was as depraved as he sounded, or whether his crudeness was partly bluster. "I was interested in, grateful for, his last few words: the 'once in a while,'" he recalls. "Those words, added almost as an afterthought, seemed to suggest some scrap of self-consciousness or shame." Knowing that his patient was close to his teenage children, Yalom decided to turn the tables on him.

"All right, Carlos, let's consider this ideal society you're imagining and advocating. Think now, for a few minutes, about your daughter. How would it be for her living in this community—being available for legal rape?" At that point, Carlos' macho mask begins to crumble. He winces visibly and stammers that he wouldn't like that for her. What he wants, he says, is for his daughter to have a loving relationship with a man, and to have a loving family. Again, Yalom presses him to confront his own words: "But how can that happen if her father is advocating a world of rape? “If you want her to live in a loving world, it's up to you to construct that world—and you have to start with your own behavior.”" The discussion was so difficult for Carlos that he became faint, but shortly thereafter he was able to change his cynical approach to other people. Following this breakthrough, he was able to rejoin the group that had rejected him and, in the months before his death, to enjoy a number of close, supportive friendships with the women and men there.

Therapist Blunders and Breakthroughs

As in any other intimate relationship, Yalom feels that it is important for both parties to admit when they have made an error or blunder. He notes that when he has owned up to his own limitations and lack of understanding, it has often led to an important breakthrough in therapy.

Such was the case when Yalom found himself extremely uncomfortable while counseling a chatty, obese woman suffering from depression—another story he relates in Love's Executioner. He takes us through his challenging journey to understand his resistance to treating "Betty," beginning with his family and its line of "fat, controlling women," to his need for a scapegoat in his high school years in racially segregated Washington D.C., in which he was regularly attacked for being white and Jewish. (Yalom recalls that he, in turn, could look down on the "fat kids": "I supposed I needed someone to hate, too," he reflects. "Maybe that was where I learned it.") In the process of therapy, Yalom persuades Betty, who deflects most of his questions with a joke, to stop trying to "entertain" him and to talk about her life with the seriousness it deserved. When she does, he eventually conquers his discomfort and comes to feel an enormous respect and liking for his patient. And, after some months of treatment, Betty is able to overcome her depression and achieve a more comfortable weight for herself.

A Doctor Making House Calls?

Yalom's personal involvement during therapy doesn't stop with sharing his own biases. By occasionally visiting patients at home, Yalom says he has learned important information that he's been able to put to good use in therapy. For example, one severely depressed patient was for months unable to move beyond the initial phases of grieving over his wife's death. When Yalom made a house call, he found that the patient had so saturated his environment with material reminders of his wife—to the point of keeping the ratty sofa where his wife had died on prominent display in the living room—that his own personality had all but disappeared.

Together, patient and therapist worked out a series of changes in the house that would help free the patient from some of the invisible chains that bound him.

Patient as Fellow Traveler

Because building trust and intimacy takes time, Yalom is critical of the current trend towards short stints of behavioral therapy. While they may work in some instances, he allows, there is no substitute for ongoing, weekly sessions in which a caring doctor and a troubled patient engage in a "dress rehearsal for life." Although the "life" in question is usually the patient's, Yalom feels that if change does not occur in the therapist as well, the therapist is not working effectively.

Forty-five years of clinical practice have led Yalom to note that “the patient and therapist are "fellow travelers" in therapy—they're both human beings dealing with essential problems of existence and must work cooperatively to solve them.” The therapist must be able to "look out the other's window." Learning to actively empathize with a patient's experience is the most important gift a therapist can give a patient, Yalom says.

Certainly the world of analysis and therapy have changed dramatically from the days of glorifying the neutral, distant and emotionally removed therapist with a pipe in hand. In particular, Yalom's works pose a far-reaching question: Is it time for psychoanalysts and psychotherapists to reveal more of themselves to their patients? And, in addition to challenging their patients to grow, should they remember to treat them with empathy and simple human kindness beyond that of the detached professional caring? In The Gift of Therapy, Yalom makes the brave assertion that the therapist is responsible for bringing his or her own humanity to the forefront of the therapy. After all, this may be the most valuable gift that the therapist can offer the client.

References

Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. NY: Harper Collins.

Yalom, I. D. (1989). Love's Executioner and Other Tales of Psychotherapy: For Anyone Who's Ever Been on Either Side of the Couch. NY: Harper Perennial.

This article is adapted from an article originally published on the Consumer Health Interactive website (www.yourhealthconnection.com) (2002).

In Search of Self: My Therapy with Rogers, Satir, Bugental, Polster, Yalom, & Maslow

Posted on by rezendevknowfully.com
Have you ever wondered what would it be like to work with psychotherapists who most of us have only read about, heard speak at a conference, or watched on video? Like many psychology students, I have often pondered the question of what it would be like to meet with the masters in our field. At critical crossroads of my life, I have wished for the guidance of these sages. In my mind, over the years, I have assembled my own personal therapist dream team: Carl Rogers, Virginia Satir, James Bugental, Erving Polster, Irvin Yalom, and Abraham Maslow. (I suspect each of us could construct our own cadre of master therapists.) What these therapists have in common is that they all value the importance of self-determination, autonomy, and the intrinsic potential for growth. They all seek to provide the optimal conditions for individuals to heal and grow, despite the pressures and circumstances of life. By helping to remove any obstacles towards growth, these therapists empower individuals as they let go of their symptoms and engage more fully in their lives.

I have imagined what it would be like if each of these renowned professionals could share with me their unique approaches and help me understand myself, confront my struggles, and achieve my potential. I invite you to join me now, in eternal time and space, as I begin my psychotherapy encounters with my dream team. But first, here's a little background.

In Search of Acceptance

For as long as I can remember, I have always been a high achiever. My relentless drive for perfection earned me countless academic awards and recognitions. I knew that as long as I succeeded academically, I would be accepted in the eyes of others. Continuing to persevere, I earned a master's degree in chemistry from Stanford University. I was proud of my academic achievements, but I had always sensed that my heart wasn't  there.

For the next several years, I was on a mission to find my passion in life. Although I had not been successful in finding a fulfilling career, I was determined to find a relationship that would make me feel whole. Depressed and frustrated, I entered therapy when I could not convince my ex-boyfriend Brian to give me just one more chance. I was determined to be the person I needed to be so that he would accept me and come back into my life. I was convinced that if he could accept me, then I could finally be happy.

Carl Rogers: Conveying the Core Conditions

Rogers Intro: During Deb's first therapy session with me, she tearfully commented, "I have lost my direction in life, and I do not know where I am going." She explained that her job as a researcher was "just not me" but she did not know what else to do. She described how the security of having an income helped her overlook the reality that she did not enjoy the work. After the first half of the session, Deb started to describe her "on-and-off" relationship with her ex-boyfriend Brian.

Deb: From the moment I met him, I knew he was the person I had been searching for. We had so much in common and we seemed to understand each other pretty well. I remember him telling me how I was one of the few people who could really understand him and be on his wavelength. I still remember how nice it felt on our first date when I made him laugh. After that first date, I knew I was hooked.

Rogers: It sounds like that first date with Brian was a really special time for you. He recognized you as someone who could understand him, and when he laughed you felt as if he could really appreciate you.

Deb: Yes, that's exactly how I felt. And I felt so safe with him. I know this may sound kind of silly, but I took so much comfort in the fact that he was so tall and strong. When I was in his arms, it felt like nothing else mattered. Being with him provided me an escape from the rest of my life…and from myself.

Rogers: That does not sound silly at all. By escaping to Brian, you felt as if you could escape from your problems. But, in doing so, it sounds like you also lost parts of yourself.

Deb (crying): You're right. I used to feel so strong and have such a clear idea of who I was. But since I started depending on him to be the source of strength in my life, I've had no clue as to who I am. All I can think about now is doing what I need to do to get him back into my life again.

Rogers: Your tears show what a compassionate and sensitive person you are. I see how much pain you are in now, but I also hear how determined you are to discover your true self. Just the fact that you are here shows that you are ready to find your "direction in life."

Rogers Wrap-up: My main goal with Deb was to create a growth-promoting environment by helping her identify and remove the internal and external obstacles blocking her inherent growth. Conveying the core therapeutic conditions of accurate empathy, unconditional positive regard, and genuineness, I helped Deb realize and accept her congruent self and begin her growth process toward self-actualization. As Deb started to move in the direction of growth, I noticed she was developing openness to experience, gaining a trust in herself, developing an internal locus of evaluation, and demonstrating a willingness to continue to grow. She was beginning to discover her own strength—instead of escaping to that of her ex-boyfriend. During our final session, Deb mentioned that she was even considering her long-term goal of enrolling in a psychology graduate program.

Virginia Satir: Engineering the Self

Satir Intro: After attending one of my personal growth workshops, Deb approached me about helping her in the process of rediscovering and rebuilding her self. Always enthusiastic to help an individual in the area of personal growth, I agreed to see Deb right away. When I met with her during our first session, I had the sense that she had the motivation to grow, but she just needed a little direction to help her stay on her path.

Deb: I know that I should be ready to move on, but I still find myself feeling so sad over the end of my relationship with Brian. I wish I could just ignore my feelings, but it seems there's no escape.

Satir: I think that it is great you are so in touch with your feelings now. Maybe it would help if you could think of these feelings as the "juice" that keeps you in a whole piece and gives you the abilities to see better, to think better, to feel better. By owning these emotions, you can actually feel more alive.

Deb: That sounds much better than trying to fight these feelings. But as I am dealing with all of these feelings, how do I get unstuck? I just don't understand why I can't move on with my life!

Satir: Anytime we try to change something that has been a part of our life for so long, it's so tempting to stay with what's familiar. Often when we try to take one step forward, the familiar brings us right back. This struggle you are having is certainly a common one. Just ask anyone who has ever tried to quit smoking, or change any kind of habit.

Deb: That definitely helps me put things in perspective. But, how do you suggest I break my "habit"?

Satir: Changing oneself is one of the most difficult things in the world to do. I think the most important tools you need to have now are faith in and forgiveness for yourself. Your faith will help you move forward in your commitment to grow, and your forgiveness will save you during the backslides. I see just how committed you are, and I know that you're going to keep on moving ahead, and eventually you're going to be able to make it.

Deb: Thanks for the encouragement. But, I have to admit it's those backslides you just mentioned that scare me the most. I am just not sure how to find the strength and courage to move on when I feel like I've taken a step backwards.

Satir: The pulls back into the familiar are indeed powerful. If you find yourself doing the familiar, my advice would be to give yourself an "A" for being so aware. Then, you can give yourself the choice about what you want to do next. After all, you own yourself, and therefore you are the engineer of yourself.

Deb: Oh, I really like that idea. So if I don't like the way I am doing something, I have the choice to do it differently.

Satir: Exactly. I think the key to life is to change when the situation calls for it, and to find ways to accommodate to what is new and different. It's important to keep the part of the old that is still useful, and discard what is not.

Deb: So your advice is to change what no longer works, but to hold on to what still does. That means I don't have to completely start over.

Satir: That's right. You already have a great start on your journey. Let me read you something that I wrote a few years ago that may encourage you as you continue in your process of change: "I am Me. I own my fantasies, my dreams, my hopes, my fears. I own my triumphs and successes, all my failures and mistakes. I have the tools to survive, to be close to others, to be productive. I am me, and I am okay."

Satir Wrap-up: During our next sessions, I helped Deb to develop ways to cope with the ending of her relationship. I helped her understand that in our lives, problems are not the problems—coping is the problem. I pointed out to Deb that life is not what it's supposed to be. It's what it is. The way one copes with it is what makes the difference. She eventually saw the ending of her relationship as an opportunity for positive change, which would ultimately make her stronger for the upcoming "bumps in the road." Over the next few months, Deb developed the strength and self-esteem to directly confront many of the everyday challenges she faced in life. I enthusiastically watched her become stronger and stronger with each of these encounters. During our last session she admitted, "It's much easier to face a problem directly than to try to find the energy to avoid it."

James Bugental: Experiencing the Moment

Bugental Intro: Before she left for the Esalen Institute in Big Sur to develop their Human Potential Development Program, Virginia Satir referred her client Deb to me. She felt that Deb was beginning to trust herself and her feelings, and she thought that I might be able to help her tune into her "Wisdom Box" to access her inner truth. During our first few sessions, I realized that Deb was more in tune with the needs of others than with those of herself. Then, during our fourth session, we had a major experiential breakthrough.

Bugental: When you were in the waiting room, I noticed that something seemed different with you today.

Deb: Oh, really? That's interesting you sensed that. I think I'm okay…

Bugental: Right when I saw you, I had this feeling that you had contact with Brian this week.

Deb: Wow, you're right. I did. That's kind of freaky you could pick up on that!

Bugental: I notice you are shaking right now.

Deb: I am? Oh, you're right, I am. Maybe it is because my blood sugar is low or something…

Bugental: And?

Deb: So, you're right. I did see Brian this weekend. But, everything is fine. I feel totally in control, and I am not afraid of spiraling backwards again. I think I'm ready to have him in my life again.

Bugental: Did you realize that as you said that your leg started shaking even more?

Deb: Uh, yeah. I can't quite stop that.

Bugental: What do you think your shaking is trying to say to you?

Deb: I don't know.

Bugental: Can you ask it?

Deb: Well…maybe it's trying to tell me that I'm not ready to have him in my life again. Perhaps it's a reminder of all the pain I have been through before, and a warning not to go there again.

Bugental: It's almost as if his being in your life threatens your stability and "shakes" your foundation of strength, and even chips away at your bedrock of self-esteem. Does that sound right to you?

Deb: Wow, you know I didn't think of it that way. But, yes, there is definitely some truth in that.

Bugental: Now I see you're shaking even more. What are you feeling now?

Deb: Oh, so many feelings are going through me now, I don't even know where to start.

Bugental: What if you just close your eyes now and breathe in and out. Now imagine what your shaking leg is trying to tell you. With all of that energy, it must have an important message for you. Just concentrate on what it is saying.

Deb (tearfully): It is saying that it is time for me to be seen, heard, and respected. It is realizing that I've been so busy taking care of other people's needs that I have not been in tune with my own. Brian really has no respect for me, and I'm so sick of being a doormat!

Bugental Wrap-up: During my next several sessions with Deb, I assisted her in tuning into what she was experiencing in the moment. In essence, by helping Deb to focus on the present and become mindful of what was happening in the here-and-now, I helped her become more self-aware. Then, by reflecting her newfound awareness back to her, I assisted her in better comprehending her situation, and ultimately increasing her choices so she could begin to make a change. It was also essential for me to enter into Deb's world without disrupting it and changing her personal experience. I wanted to help Deb discover her own images, without intrusively bringing in my ideas. I also wanted to challenge her to look at her own attitude towards herself. This process was aimed at facilitating Deb in taking charge of her life, and ultimately claiming her power to engage in her journey toward self-actualization.

Erving Polster: Gaining Awareness through Gestalt

Polster Intro: I received a call from Deb, a graduate student in psychology, who was interested in learning about how my Gestalt approach might help her achieve a new level of awareness. She explained that she would like to get in touch with and unleash the anger that she had been internalizing all her life. I agreed to help in her process. Right when I met Deb, I sensed she was ready to get to work.

Polster: I'm wondering how you have been able to get in touch with your anger in the past.

Deb: To be honest, I've always been afraid of getting angry at people. It just seems more natural to keep it locked inside.

Polster: What if we could try something that might help you unlock this anger before it breaks down the door on its own?

Deb: I'd be up for that. But how would I do that?

Polster: How about you just imagine that Brian is sitting there in that empty chair right now. Get in touch with how you feel that he just entered and left your life again. What do you want to say to him?

Deb: Um, that I'm mad.

Polster: Tell it to the chair. And say it like you really mean it.

Deb (angry): You just don't have a heart. I was trying to understand how your coming into my life again could make sense to you. And then I realized you didn't just think—you knew, you totally knew, that you were going to come into my life for a limited amount of time, and then just leave. There was no thought in there of me at all except what I could do for you. It's all about you!!

Polster: That's it. Now go even deeper into that anger.

Deb: I just don't get it. And I'm just really mad that you could just come into my life again, and show me the side of you that I missed. Then, when you were no longer lonely, you just left my life again. I'm so sick of this!

Polster: Go to the core of your anger. What do you really want to tell him?

Deb: I've always been there to support you. I've never ever, ever let you down. I've always been there for you and there have never been any consequences for you. But you're never here for me, Brian! It's such a one-way thing. I can't count on you for anything except to be a fleeting part of my life. That's all that I can expect from you, and I'm done with you! I deserve better!!

Polster: Where is your anger now? Where do you feel it most? Let it out.

Deb (raising her voice): Stay out of my life! Stay out of my life, Brian!!!

Polster Wrap-up: Gestalt therapy served as an effective means for Deb to become more fully present with her unexpressed emotions. When she could be more in the "now," she developed a clearer sense about the growthful direction in which she needed to move—i.e., away from her ex-boyfriend—and her change naturally unfolded. Her previously alien anger was transformed into an acceptable expression, which ultimately led to new possibilities in her life. During the next few months, Deb's increased self-awareness enabled her to take back her power and restore her self-support. Her new awareness also allowed her to experiment with new behaviors, which, in turn, facilitated further growth. Deb realized that finally giving a voice to her anger allowed her to focus her energies on her interests and passions, instead of on her regrets and fears.

Irvin Yalom: Confronting the Existential Givens in the Here and Now

Yalom Intro: I received an enthusiastic email from Deb who explained to me how my book, Existential Psychotherapy, had made quite an impact in her life. Since she was living nearby, she expressed her desire to consult with me on her existential quest, and I agreed to meet with her. When we met in my office, I could not help but notice that Deb seemed a bit star-struck. (And, of course, I have to admit that this is indeed a nice reaction for a man in his 70s to encounter.) But these stars soon faded, and we got down to the business of her life.

Yalom: Hi Deb—it's really nice to meet you in person.

Deb: Wow, thanks. Uh, I'm feeling a bit nervous right now. I've been admiring your work for so long, and I just can't believe that you are right here in front of me now!

Yalom: It's nice to know that you've been able to appreciate my work.

Deb: Not to sound like a groupie or anything, but in many ways that book changed my life. Especially my ability to really begin to let go of a painful relationship I was having with my ex-boyfriend Brian.

Yalom: Now you've got me curious. What in the book helped you the most in being able to move on with your life?

Deb: Where do I begin? Let's see…well, your whole premise that underneath all of our motivations and experiences lies this "existential bedrock" which forces us to be aware, on some level at least, of life's existential givens of death, isolation, freedom, and meaninglessness, really hit home with me. At first this concept was just an intellectual one to me, but as I drank in each word of your book, I realized that these concerns lie at the origins of my major life challenges.

Yalom: Yes, I have observed time and time again how both on a conscious and unconscious level, these "givens of existence" constitute the core struggles of humankind. It is these ultimate concerns that provide both the process and content for therapy.

Deb: Your book convinced me of that! While I was in the midst of reading through the chapters on death, I did a lot of thinking—and dreaming—about death. In fact, one night I had the most terrifying nightmare that death was literally at my door, and I had to use all of my energies to protect myself from it. Until that dream, I did not realize how fearful I actually was of my own death. And, that's when I realized that my "death grip" on Brian represented my attempts to assuage my death fears by believing that he was my "ultimate rescuer" who would protect me from death.

Yalom: Wow, what an insight.

Deb: Interestingly enough, when I was able to confront the inevitability of my own death on such a deep level, I became more engaged in my life.

Yalom: That's the paradox of accepting death—although the physicality of death destroys us, the idea of death saves us.

Deb: I also discovered a similar paradox regarding existential isolation. I realized that my irrational quest for unconditional (and unrealistic) acceptance from Brian was actually a form of denying my existential isolation. But once I was able to confront the reality that I was ultimately alone, I have felt so much less lonely!

Yalom: As you've discovered, the fear of existential isolation is the driving force behind many interpersonal relationships. But true relationships do not use the "other" as the functional "it" to guard against existential isolation. Once a person can accept that they are ultimately alone and can not have all of their needs met by others, then they can develop richer, more tolerant, and more loving relationships based on a deeper sense of communion. When we are able to stand alone and dip within ourselves for our own strength, our relationships with others are based more on fulfillment, not on deprivation.

Deb: Wow, what a comforting thought!

Yalom: Indeed it is. It is only by facing aloneness that we can meaningfully and authentically engage with another. Love—although it doesn't take us away from our existential isolation—is our best mode for coping with the pain of separateness.

Deb: So in a sense, we are all together in our separateness.

Yalom: Yes, that's very true. We are separate but can still connect to each other.

Deb: In addition to helping me gain personal insight into the existential concepts of death and isolation, your book also gave me the opportunity to process my thoughts about freedom. Your concept of freedom—that everyone is ultimately responsible for their (and only their) life and has the choice to make (or not) decisions and change their life as needed—is pretty much the very core of my whole outlook in life.

Yalom: Good for you. I've found that many people are actually frightened by the concept of freedom which implies that beneath them exists a "groundlessness" lacking any form of structure. But you seem to have to come to a place in your life where you are accepting this freedom and realize that you can create your life by the process of feeling, wishing, willing, choosing, acting, and changing.

Deb: My recent realization based on this concept—that I am the one who is responsible for both my needless suffering over Brian as well my solution to search for alternatives that really honor who I am and what I want—has brought me an incredible sense of empowerment! Your idea that we are responsible for our own lives and well-being has become my new mantra!

Yalom: As I've always said, until one realizes one's own role in contributing to one's problems, there can be no motivation to change.

Deb: I'm a true believer in that idea! And the final section of your book on meaninglessness really gave me plenty of food for thought too.

Yalom: Oh yes, the riddle of the meaning of life…Since the beginning of time, people have struggled with the classic existential dilemma of seeking meaning and certainty in a world that can offer them neither.

Deb: I loved your idea of engagement in life as the antidote to meaninglessness.

Yalom: Yes—it's better to embrace the solution of engagement rather than become preoccupied with the problem of meaninglessness. I have discovered that one must immerse oneself in the river of life and let the question drift to the background, attending to it when necessary.

Deb: I completely agree. And, I've found that approaching life's inherent meaninglessness with the realization that it's up to each of us to create and aspire to fulfill our own meaning is quite a satisfying way to live.

Yalom: Wow, so I see that you have really explored these existential concepts in a way that makes sense for you. Sounds like you've been able to put theory into practice.

Deb: I think so. If the whole point of theory really is to serve as a foundation and help one achieve a sense of order and control in an otherwise chaotic world, then I think I'm finding mine!

Yalom: It is so nice to know that my books have been able to offer you so much insight into your life. Now, I'm wondering how that felt for you to share with me how much you've enjoyed my work and put it into practice in your own life.

Deb: Hey, that sounds like an attempt to bring our session back to the "here-and-now"!

Yalom (laughing): Okay, now I'm convinced that you may have read a few too many of my books. But it was a serious question. You must have had some image of what this would be like. So, how has it been for you to meet with me in person? Any surprises so far? Any disappointments?

Deb: I admit I was nervous prior to our meeting. I guess I was intimidated by all the books you have written, and by the fact that you're, uh, Yalom! I was hoping that I would not embarrass myself. But, much to my surprise, soon after we met, it was easy to open up and talk to you about myself and existential issues.

Yalom: So it sounds like you are pleasantly surprised that you feel comfortable talking with me. Anything else that you wanted to share today, but have not?

Deb: Well, let me think about that for a moment. I guess we have been talking a lot about existential issues and struggles I have dealt with in the past. Maybe I was trying to impress you with my knowledge (smiles sheepishly). But I have not revealed much about what I want to work on in my life now.

Yalom: I appreciate you telling me that you wanted to impress me. You have succeeded on that count! But it sounds like your desire to impress me might have gotten in the way of you sharing more pressing needs. Maybe I played some part in that as well, but we don't have much time left today, so maybe we should use that time to begin talking about what you would like to work on now in your life.

Deb: Yes, I would. This is little harder for me, but here goes…

Yalom Wrap-up: Deb continued to meet with me on a weekly basis until the end of the summer. As our sessions progressed, she focused less on intellectual topics and more on the here-and-now space between us. During our last session, Deb explained to me why our therapeutic relationship had been so valuable to her. With tears in her eyes, she told me that she could now truly understand my maxim of psychotherapy that "It is the relationship that heals."

She explained how she particularly enjoyed my approach where I saw us as "fellow travelers" in a world full of inherent tragedies of existence, and she appreciated how I could be both an observer and a participant in her life. She mentioned that although she had previously read how I entered each therapeutic relationship with openness, engagement, and egalitarianism, she was amazed to personally experience the true power of these therapeutic ingredients. Deb realized that what had been most helpful about our sessions was how my authenticity, genuineness, and transparency eventually allowed her to discover these same qualities in her self. I explained to her that this is precisely why I have always believed that therapist authenticity is ultimately redemptive. She also realized that my being able to enter into her world and see her as she truly was enabled her to do so herself. As she hugged me at the end of our last session she said "Thank you for giving me the gift of therapy."

Abraham Maslow: Journeying toward Self-actualization

Maslow Intro: When I ran into Irv Yalom at the Evolution of Psychotherapy conference, I mentioned to him that I was in the process of revising my book Motivation and Personality. After he got over the shock of seeing me (he really did look like he had seen a ghost!), I expressed to him that I have always enjoyed how his textbooks read more like novels with their captivating vignettes, and that I was currently using this technique to revise my text. When I mentioned that I wanted to work with people who were on their journey toward self-actualization, he told me he knew of a person who might be interested in meeting with me.

A few days later Deb called me, and her pursuit of self-actualization was evident right away. I decided that it would be helpful to meet with her a few times to discuss what was on her mind. I met with Deb for the first time after she just finished a day full of play therapy sessions with young children. I could not help but notice that she was sparkling—both literally due to all the glitter she had on her from doing art therapy with the children, and also figuratively from finding work that allowed her to shine from the inside out.

Maslow (jokingly): Wow, it looks like you're really getting into your work with the children!

Deb: Oh yes—and on so many levels too! I've always been drawn to children. When I'm with them, I just feel myself light up.

Maslow: And I'd guess that illumination lights the path for both you and them.

Deb: It certainly feels that way to me. I noticed that being able to see them has also given me the ability to see myself. When I was working with children at my school's expressive arts camp this summer, I discovered that what the kids needed most was to be seen, heard, and understood. Soon after, I realized that that's exactly what I need to give myself as well.

Maslow: So the work you are doing with children reflects and invigorates the work you have been doing with yourself.

Deb: Yes, I feel that what I have been able to provide the kids is also what I am learning to give myself. In the therapy room, I give each child the freedom to be themselves while I honor, reflect, and validate their individuality. In life, I try to give myself these same opportunities.

Maslow: It sounds like being in tune with the children has helped you to become in tune with you own inner voice.

Deb: Exactly. And, paradoxically enough, I'm discovering that listening to the child inside of me has been the best way for me to navigate through my life as an adult. Now I trust my feelings. If something doesn't feel right with me, I know that it's not. It is also increasingly clear to me when I am doing something that is congruent with who I truly am inside.

Maslow: That reminds me of the quote "To thine own self be true."

Deb: That quote really resonates with me. Before I started therapy, I measured my successes in education, career, relationships, and life choices through the eyes of others. I was motivated by external rewards. But now, I just follow my heart.

Maslow: It sounds like you have discovered that the only way for you to lead an honest life is by following your own inner truth.

Deb: Yes, that has been my most powerful discovery.

Maslow: How would you describe your life now?

Deb: Well, I feel like all of my life I've been carrying around these unopened gifts. And, now, I've reached a place where I can finally unwrap them. Being able to enjoy these gifts with myself and share them with others has given me such a sense of inner peace.

Maslow: Wow. You seem to have discovered your true self.

Deb: And, I'm happy to say that I really like my discovery.

Maslow Wrap-up: When Deb started on her therapeutic journey several years ago, she was motivated by what I have termed the "deficit needs," or "D-needs." Although her physiological and security needs had been met, she was struggling to fulfill her higher needs of love/belonging and esteem. Lacking a satisfying relationship as well as a sense of community, Deb was increasingly susceptible to loneliness and relationship difficulties. Furthermore, not feeling respected by others (or even herself at times) Deb experienced an all-time low in her self-esteem. Fortunately, through her hard work in therapy, Deb has been able to make changes in her life—including pursuing her graduate studies in psychology and moving away from her relationship with her ex-boyfriend—which allowed her to satisfy her love/belonging and self-esteem needs.

Since I started my work with Deb a few months ago, I have noticed that she has devoted herself to fulfilling her potentials. Instead of being motivated by deficits, she is now motivated by growth. Striving to satisfy her "being needs," or "B-needs," she has reached the self-actualization level of the hierarchy of needs. As she feeds these higher needs, they are becoming increasingly stronger, as is her desire to realize her potentials. Whereas Deb once relentlessly strove to gain the acceptance of others, she now enthusiastically thrives in being true to her own nature. Deb has recently discovered that what she can be is also what she must be.

Discovery of Self

My therapeutic encounters have inspired me in my search to discover more about myself. When I started my therapeutic journey, Carl Rogers' use of accurate empathy, unconditional positive regard, and genuineness facilitated my ability to begin to see my true self. Next, my sessions with Virginia Satir helped me to understand and embark upon the process of change. My sessions with James Bugental allowed me to recognize my unvoiced anger, while my Gestalt work with Erving Polster encouraged me to express this anger. After Irvin Yalom's book, Existential Psychotherapy, provided me a valuable framework for understanding my life, my here-and-now encounters with him allowed me to experience the healing power of the therapeutic relationship. Finally, my work with Abraham Maslow offered me an opportunity to reflect on and appreciate my journey toward self-actualization.

While it was my search for external truth that brought me to therapy, it was the discovery of my internal truth that brought me back to life. My therapeutic journey has allowed me to identify and overcome obstacles to my growth, while recognizing my inherent potential. By pursuing a path of self-reflection, self-examination, and openness to new experiences, I have been able to engage more fully in meaningful goals and fulfilling experiences in my life. As I continue on the path of my life, I take with me a greater sense of my authentic self that my therapist dream team helped me discover.

Resources on Deb's Psychotherapists

Branfman, F. (1996). "A matter of life and death." (Interview with Irvin Yalom.) Salon.
Retrieved November 20, 2006, from: http://www.salon.com/weekly/yalom960805.html.

Bugental, J. F. T. (1992). The art of the psychotherapist (1992). W.W. Norton, NY.
Zeig, Tucker & Theisen.

Bugental, J.F.T (2006). Existential-Humanistic Psychotherapy in Action. San Francisco: Psychotherapy.net.

Bugental, J.F.T (1997). Existential-Humanistic Psychotherapy, in Psychotherapy with the Experts Video Series. San Francisco: Psychotherapy.net.

Bugental, J.F.T (2008). James Bugental: Live Case Consultation. San Francisco: Psychotherapy.net.

Bugental, J. F. T. (1999). Psychotherapy isn't what you think: Bringing the psychotherapeutic engagement into the living moment. Phoenix, AZ: Zeig, Tucker & Theisen.

Bugental, J.F.T (1988). The search for authenticity: An existential-analytic approach to psychotherapy. NY: Irvington Publishers.

Maslow, A.H. (1968). Toward a psychology of being. NY: Van Nostrand Reinhold Company.

Maslow, A.H. (1987). Motivation and personality. NY: HarperCollins Publishers Inc.

Polster, E. A. & Polster, M. (1974) Gestalt therapy integrated: Contours of theory & practice. NY: Vintage.

Polster, E. A. (1990). Humanization of technique. Phoenix, AZ: Milton Erickson Foundation.

Polster, Erving (2006). Psychotherapy with the Unmotivated Patient. San Francisco: Psychotherapy.net.

Rogers, C. R. (1961). To be that self which one truly is: A therapist's view of personal goals.
In Rogers, C. R. (Ed.), Becoming a person (pp.163-182). Boston: Houghton Mifflin.

Rogers, C.R. (1977). Carl Rogers on personal power. NY: Delacorte Press.

Satir, V. M. (2001). Self esteem. Berkeley, CA: Celestial Arts.

Satir, V. M. (1988). The new people making. Palo Alto, CA: Science and Behavior Books.

Satir, V. M., and Baldwin, M. (1983). Satir step by step: A guide to creating change in families. Palo Alto, CA: Science and Behavior Books.

Yalom, I. D. (1980). Existential psychotherapy. NY: Basic Books.

Yalom, I.D. (2008). Irvin Yalom: Live Case Consultation. San Francisco: Psychotherapy.net

Yalom, I. D. (2000). Love's executioner. NY: First Perennial Classics.

Yalom, I.D. (2003). The gift of therapy. NY: HarperCollins Publishers Inc.

Yalom, I.D. (2006). The Gift of Therapy: A Conversation with Irvin Yalom, MD. San Francisco: Psychotherapy.net.

Yalom, I.D. (2006). Understanding Group Psychotherapy, Volumes I – III. San Francisco: Psychotherapy.net.
 

Healing Trauma Through the Body: The Way In is the Way Out

Posted on by rezendevknowfully.com

Suzanne: A Case Study

Suzanne* arrives in my office due to a long history of anxiety, mild depression, problems sleeping, and relationship issues. She is 43, successful in her marketing career, and divorced, with a child in high school. She is a tall woman, but something about the way she carries herself makes her seem smaller than she is. She is wearing loose, dark clothing that doesn’t reveal much of her body. As she walks into my office for our first session, I am struck by the animation in her upper body, but I notice that she moves awkwardly because of the tightness in her shoulders, neck and upper spine. As I invite her to sit down, I notice that her eyes shift back and forth as if she’s looking for something. She seems uncomfortable meeting my gaze and looks quickly down at the floor each time our eyes meet. I can see by the way her shirt lies that her solar plexus area is very tight. It is clear that this tightness prevents her from taking a full, deep breath. She seems to be fighting upward against gravity, as if attempting to levitate. At the same time, I see and sense very little connection to her lower body. Her legs are almost completely still; they appear lifeless and detached. This gives her a weak and tenuous connection to the earth. “It’s as if everything from above the waist is surging wildly upward, like a thousand bees swarming skyward, out of a hive, centered above her navel.”
 
She complains of rapid heart rate, shallow breathing, food sensitivities, digestion problems, and difficulty staying asleep. As she talks, I can hear her mouth is dry. It makes sense to me that she is experiencing anxiety—my understanding of how the nervous system works lets me know that her system is stuck in a constant state of fear and readiness. As a Somatic Experiencing® (SE) practitioner, I can tell that Suzanne is in a common feedback loop that occurs in people who are attempting to manage their internal nervous system dysregulation. Shallow breathing and tightness in her chest keep her body in a constant state of oxygen deprivation. This escalates the anxiety, so she tightens the muscles in her chest even more. I take a mental note—I’ll need to address this pattern.
 
Suzanne begins to tell me about a recent conflict she experienced at work with a male co-worker. As she describes the situation, she cries easily but not comfortably, trying to hold back the tears. When she does begin to cry, she holds her breath and squints her eyes tightly, as if trying to squeeze the tears back into her eyes. She swallows repeatedly and her shoulders tighten even more. She’s working hard to keep the emotions in check. At one point in her description, she chastises herself for being so reactive. “I should be able to handle these types of situations,” she says. “Instead, when there’s conflict, I get totally emotional. Even though my mind is racing with thoughts, I can’t do or say anything. I feel paralyzed. I don’t act like a competent professional. I just sit there and cry like a little girl.”
 
She looks down, rounds her shoulders, and holds her breath. I listen to her words and make a note of how she describes her experience, but I am especially paying attention to what her body is telling me. “As I listen to her, I’m receiving a lot of information about her by paying attention to my own bodily experience.” I feel a little breathless and pulled upward in my own body—I need to keep reminding myself to breathe, soften my belly, and feel my feet and pelvis.
 

Approach

It is obvious from the above description that my attention is heavily focused on the physical presentation of the client.  Of course, I am not ignoring the content of her narrative, but I am especially attuned to the story her body is telling. My approach is guided by the principles of Somatic Experiencing, developed by Peter Levine from his research into the stress responses of animals in the wild. Physiological responses to stressful situations arise from what is classically called the sympathetic or “fight-or-flight response.” Levine noticed that once an animal was out of danger, its body automatically shifted to “parasympathetic” rest and recovery with gentle trembling, shaking, deep breaths, sweating, and sometimes more aggressive fight-reenacting behaviors—a process called discharge. These behaviors reset the nervous system to a pre-threat level of functioning. This discharge cycle appeared to be essential to recovery: experts repeatedly told Levine that if animals were unable to complete the discharge process, they would die.
 
Given that humans should be equipped with the same restorative capacities, Levine pondered, what makes us different? What gets in the way of our recovery? 
 
Through hundreds of hours of client sessions, Levine began to witness how clients’ bodies told their stories of trauma, even if the clients had no specific memories. Once Levine guided them into the sensate experience of trauma, the body then took over and finished what was unprocessed, or incomplete, much like the animals he’d observed. Clients receive the added gifts of increased body awareness, a stronger connection to self, a shift in deep-seated patterns, a more regulated nervous system, and a sense of mastery.
 
Why do humans need to be guided at all? The biggest obstacle is how inattentive and unfamiliar we are with our physical sensations. Our big, sophisticated brains constantly out-think and override our bodily needs. We are trained to ignore signs of hunger, pain, discomfort, injury, danger, as well as pleasure, saturation, and fulfillment. What’s astonishing is how forgiving and responsive the body is. As soon as we tune into it, shifts begin to happen.
 

Getting Unstuck

Within my framework as an SE practitioner, Suzanne’s symptoms imply something in her system is stuck, unfinished. I can assume that during some traumatic experience in her past, she froze or was overpowered by someone or something bigger, stronger, or faster. 
 
Suzanne’s array of emotional and physical complaints is typical of autonomic dysregulation. Dysregulation shows up in basically two extremes: stuck “on” and stuck “off.” The former can manifest as anxiety, panic, mania, hypervigilance, sleeplessness, dissociation, attention deficit, OCD, emotional flooding, chronic pain, hostility/rage, etc. This is the sympathetic branch of the nervous system, responsible for moving us out of danger. When traumatic material is unprocessed, the residual activation keeps a person locked in a constant state of readiness and reactivity. The client has an ongoing sense that “something bad can happen at any moment.”
 
Being stuck off shows up as depression, flat affect, lethargy, exhaustion, low impulse/motivation, chronic fatigue, dissociation, many of the complex syndromes, low blood pressure. This is the parasympathetic branch of the autonomic nervous system. In a healthy state of functioning, it is designed to bring the body back to rest and recovery after surges of sympathetic activity. When it goes awry, the system slows or shuts down too much, or “depresses” itself at the slightest trigger.
 
Clients may present with one extreme or oscillate between the two. At first glance, Suzanne presents more on the sympathetic scale, excepting her legs. I’ll want to guide her inward so we can begin to sense more deeply into her pattern.The goal of SE is to work through traumatizing events in non-traumatizing ways. If I can ease her through whatever defenses or strategies her body has taken on to manage the dysregulation, her body will take over and complete the necessary response that was not able to occur when she was initially traumatized. It will be part of my treatment plan with her to assist her body in feeling all possible impulses. She may want to cower self-protectively, defend herself, or run from the danger.
 
“SE therapists have to learn to watch, not just listen; to know when to slow down, when to point out and explore a physical response.” We must learn how to ask open-ended questions that invite curiosity about one’s experience in the moment. Our job is to support the client in accessing what is happening inside at the physiological level, and then to assist in the return to self-regulation. We are restoring the client’s system back to an organic level of functioning. The client grows in self-mastery, and the therapist is merely the guide.
 
SE uses a variety of techniques that are presented at a pace that helps the client to stay with every moment of the event without flooding, compensating or dissociating. Slowing everything down and keeping Suzanne focused on her bodily sensations will help us do this. It’s a bit like watching the event on a video, pausing at every single frame, and allowing each detail, emotion, sensation, bodily reaction, impulse, and defensive reaction to be felt and processed. Connecting to the physiological responses also prevents her mind from coming in and doubting or worrying.
 
In this sense, we can see that, for a traumatized person, going into the body and coming into contact with their physiological experience is the way out of their distressing symptoms. The way in is the way out. Many models of treatment focus on eliminating symptoms and behaviors, but SE takes the client into the symptoms knowing that the symptoms are the key to healing trauma. With Suzanne – as with all of my clients – I will begin my work with her wherever she is and with whatever her body is displaying in the moment. By focusing on one aspect of her physical sensations, we will be led into her body’s memory of the trauma. By moving slowly, and utilizing various techniques that prevent re-traumatization, her body will guide her through her own natural set of experiences, and gradually release the stuck pattern.
 

The Work: Careful Amplification, Attentiveness

To begin my work with Suzanne, I will want to take her into a direct experience of the physical sensations in her body. I first want to be sure that Suzanne has the capacity to work somatically with the material she is presenting. I will be able to assess Suzanne’s overall nervous system stabilization when I see how her body reacts initially as we begin to explore bodily sensations. I will also be able to get clear information on how she attempts to manage the sensations by watching her response to them. As she begins to feel her body, does she brace, collapse, tighten all over, hold her breath, dissociate, shut down, get angry or become judgemental?
 
As she is finishing her description of the conflict with the co-worker, she begins to tell me again of her general anxiety, in part, she says, because she can’t trust herself to respond in situations where she needs to. I feel as if this is a good time in the session to begin to tune into her sensations, so I ask her permission to explore her experience a little.
 
She agrees, a bit hesitantly, and I ask her to notice where in her body at this moment she is sensing the anxiety. She looks down and then says, “In my belly.” As she focuses her awareness on the sensations in her belly, she escalates quickly—her shoulders tighten, she holds her breath. She looks frightened. I remain calm and unalarmed because I have seen this many times. “Can you give me some words to describe the sensations?” I ask her. She puts her hand on her belly, and says, “It’s churning, hot, and it’s moving really quickly.”
 
At this point, “I know that I need to broaden her awareness and to help her know that she can touch into the intensity of her experience without becoming overwhelmed by it”, as well as to help her move her attention to areas of less intensity. To do this, I ask Suzanne if she can also notice the chair supporting her thighs, and the floor beneath her feet. My goal here is to build resilience and confidence, and dispel any belief Suzanne may have that she can’t handle this experience.
 
Secondly, by asking her to feel outside of an energetic hot zone, her body recognizes that there is more square footage for the intensity to inhabit. This naturally makes a little more space for the concentration of the sensations; they spread out. Thirdly, by contacting the periphery of her body, it helps Suzanne feel solid, reliable areas, which provide the sense of a container.
 
Suzanne closes her eyes and I see her body visibly settle into the chair. Her shoulders drop slightly, the muscles in her face soften and she is breathing more deeply. She seems to allow the chair to hold her a bit more, rather than holding herself up and off it. This is a very important moment and I want to grab it.
 
Suzanne looks up at me, surprised. I smile at her. “Tell me what you’re experiencing now.”
 
“Things are relaxing,” she says, her voice is softer and her words come out more slowly.
 
“What does relaxing feel like in your body?” I ask her. 

“My stomach has softened," she tells me. "I feel more air in my belly and I don’t feel as afraid.”
 
Another important moment. This is the first shift in Suzanne’s breathing pattern—a crucial element in the stuck anxiety pattern in her body. Remember, when breathing is rapid, tight and fast, it actually triggers the body’s fight-or-flight reaction. As the body goes into this reaction, the breathing becomes constricted, fast and shallow—a frustrating chicken-or-egg phenomenon. I want to expand on Suzanne’s feeling of being able to breathe. So I ask her to sense into her belly, noticing how it feels to have more air.
 

Relating to Anxiety

This experience lays the groundwork for Suzanne to be able to enter into intense sensations and then find a way to regulate them. I want her to really have a felt sense of this, so I decide to guide her into it a few times as practice. I ask her to consciously bring up something that triggers her feeling of anxiety, like her co-worker. As she thinks of him, the anxiety begins to rise again and I guide her into the sensations in her belly, then down to her feet. As we do this repeatedly, Suzanne discovers that if she moves into noticing her feet whenever the sensations of anxiety get too intense, she can stay longer and longer with the anxiety and the intensity subsides drastically.
 
I feel that we have done enough work in this area and I want to check in with Suzanne to see how she is handling this. Her face appears to be shining a bit; there is more blood flow and a pinker color to her cheeks and for the first time in the session. She smiles. I ask her about this. She looks a little sheepish, averting her gaze for a moment. Then she looks back at me and says, “This is cool. I feel so much more in charge.”
 
I want to anchor her bodily sense of being “in charge” so that she can access this when her anxiety arises. “I am hoping to help change her relationship to this anxiety—to become curious about it.” I want her to recognize that when she actually pays attention to it, at the sensation rather than emotional level, it usually subsides, rather than increases as most people fear.
 
This process of touching into her sensations of the anxiety, then shifting her awareness to the rest of her body, helping her notice any moments of settling or any shift that occurs naturally, is one of the many ways that SE supports the nervous system to re-establish its natural, inherent rhythm—one that flows seamlessly between excitation and relaxation, between contraction and expansion. This is the first step Suzanne and I have taken to restoring regulation in her system.
 

Unfinished Business

The second step we’ll need to take is to access what’s unfinished. Many traditional therapies focus on feeling, reliving, and ultimately putting behind many of the bad things that occur in childhood. While this can be an important part of the therapeutic process, and is definitely something I am concerned with, my SE orientation leads me to seek to explore this experience with Suzanne somatically. “By following the body’s wisdom, we are led to what didn’t get to happen in a client’s past.” We provide clients with the opportunity of re-doing the event—finding in the present the way that the body would naturally, organically respond if it was left to its own devices. This renegotiation is done almost entirely through visualization, and slow, intentional movements, deeply connected to sensations and procedural movement patterns. This allows the discharge process to complete, and the trauma symptoms are moved out of the body, while the nervous system is allowed to return to pre-trauma functioning.
 
To get to what is unfinished in Suzanne, I want to access the brainstem and the survival responses. The way in is via sensations, noticing physiological shifts, and sensing impulses. My work with Suzanne so far has tapped into a little (but not too much) of the activation, or the charge of the anxiety. Now it’s time to check in to the rest of her body—in particular her extremities. The extremities naturally spring into readiness and action when we feel threatened. When a person is unable to carry through with the impulse to flee or fight, these thwarted impulses interrupt hard-wired sensorimotor patterns. This is often the place where the system gets stuck.
 
Capitalizing on Suzanne’s feeling of excitement and mastery, I ask her if she’s willing to explore a bit further. This time, when she gives her assent, she doesn’t hesitate. I ask her to sense into the rest of her body to notice what else is going on.
 
She immediately reports, “I feel tightness in my legs and shoulders.”
 
Deciding to bring awareness to the less accessible lower body, I ask her to tell me where she feels the tightness in her legs. She reports feeling tension and tingling in her ankles and thighs. Suzanne’s lifeless legs indicate a parasympathetic orientation in her lower body—a common pattern in clients with a history of physical or sexual abuse, bullying, early surgical procedures, or any events that involve being restrained. Earlier she had described herself as “feeling paralyzed” and “crying like a little girl” in response to the conflict and perceived threat of her co-worker. It’s clear to me that at least some of this sense of paralysis originates in her legs. I encourage her to stay with the sensations and see what happens next as she does that.
 
“It’s getting tighter,” she says.
 
Wanting to gently encourage her, I murmur, “Stay with it, if that’s okay.” I see her legs jump and tense slightly and then become very still.
 
“I’m scared,” Suzanne says. “I want to move my legs, but I can’t.”
 
This is a very important moment in SE work—an experience that Levine describes as the brake and accelerator both floored at the same time—the core of the freeze response. It is high-level sympathetic mobilization, coupled with parasympathetic shutdown, similar to what happens when a circuit breaker blows when there’s too much charge going through a line. It will be necessary to separate the two impulses so that Suzanne’s defensive response can be completed.
 

Follow the Impulse

Before I can say anything else, Suzanne says again, “I’m scared. I know this feeling. This is like when my uncle would do things to me in the attic.”
 
While I am certain that we will need to explore the content that is beginning to naturally arise as a result of feeling into Suzanne’s sensations, at this point I want to stay grounded in her physiological experience. In my experience, if I chose to explore this reference to her uncle by asking her to tell me more about what happened in the attic, Suzanne would likely shift into an intellectual telling of the story. This would take us away from her body and what her body wants to do. In fact, her body has been telling this story from the beginning, now showing us the connection between her anxiety and paralysis in her conflict with her co-worker and her past experience of trauma.
 
I ask Suzanne if it’s okay to sense the energy in her legs.
 
She says yes, a little uncertainly. She pauses for a moment and then responds, “It feels very intense, like a strong humming feeling.” My initial impression of her “wild bee” energy seems accurate. I ask her to feel the energy and sense where it wants to go. I also ask if she can feel how she is holding it back. I encourage her to very slowly move her awareness back and forth between the wanting to move and the holding back. This technique helps to separate the conflicting impulses. 
 
Suzanne is alert and somewhat alarmed, but not overwhelmed, mostly because we have done good preliminary work earlier, where she learned to trust her body somewhat, and learned to trust her ability to handle intensity. As Suzanne tunes into the energy wanting to move, the holding begins to ease, and the impulse to move increases. I see her upper body relax slightly, while her legs begin to twitch. I point out the twitching in her legs and invite her to slowly feel that and follow what wants to happen. Her body wants to move in reaction to a threat (her uncle), but it can’t because the threat is larger, stronger and familiar. Several intense, involuntary impulses are happening at the same time: anxiety because of the danger, hormones racing through her system preparing for action, tightness and bracing in many parts of her body, feelings of helplessness, hopelessness and shame, to name a few.
 
I can see underneath Suzanne’s clothes that her thighs are contracting slightly; her feet jerk almost imperceptibly upward. I also feel the readiness in my own body, which I experience as tension in my legs; my heart rate increases. I am feeling a sense of excitement in my  body—these impulses are contagious, and many-less experienced practitioners initially make the mistake of getting swept up in the sensations, unintentionally pressuring the client and causing resistance. Not wanting her to feel pushed, I sit back, settle into the chair, and move my attention back slightly, to allow her to experience her own impulses uninfluenced by mine.
 
I ask her to feel into the tightness of her thighs, and to sense her calves and ankles. They very slowly begin to move on their own, and I encourage her to notice that.
 
““My legs feel powerful and strong, like they could leap over any mountain,” she says, her voice sounding stronger and more commanding than I’ve heard it yet in this session.”
 
“Stay with those sensations of strength and power,” I suggest to her. I can see that she is enjoying the strength she feels. She pushes her feet down into the floor, her thigh muscles contracting visibly. I see that her feet and legs continue to move very slightly, this time with larger movements. I stay alert for signs of dissociation, bracing, breath-holding—anything that would indicate that too much is happening too fast.
 
As Suzanne continues to experience the movement of her legs and feet, she says, “It feels great to move them.” Her legs pump slightly beneath her seat. “ I don’t think I’ve felt my legs for years. Its like I’m coming into them.”
 
I ask her to tell me a little bit more about what she is sensing. “Heat. Waves of heat coursing through my legs.” Her feet and ankles continue to move as she describes this. I know that the release of heat is a sign that her nervous system is coming into a greater degree of equilibrium. To continue to expand on Suzanne’s experience of becoming unfrozen, I ask her, ”What does it feel like your feet are doing?”
 
“I can walk away. I know I can walk away. I can run away if I need to.”
 
Her legs begin to tremble very slightly. Her face is flushed, radiating pleasure. I know we have done plenty for one session.
 
At this point, it's time to process some of what we’ve done. We talk about her experience and I educate her a bit on the SE model I’ve been using, explaining the fight-or-flight process of the nervous system and what happens when those natural reactions are unable to be completed. She shares some memory flashes that arose during the running, and we talk about ways she can play with the process of checking into her belly when she feels anxious—moving between the sensations in her belly and the sensations in her legs.
 

The Next Step

Future sessions with Suzanne would focus on fine-tuning the newfound skill of sensing the anxiety somatically,  and learning how to recognize it, and settle it before it overtakes her. We would look at other situations in which anxiety shows up, such as in the work place or during  moments of conflict, and see if we can generalize the skill in other settings. We would explore the abuse by her uncle, concentrating on what is unprocessed physiologically and emotionally, especially incomplete defensive responses. SE therapists learn to trust the body, more than the memory or recall of events. We know not to assign meaning or assume causality to what arises in the therapy session. Details of events change as they are worked out at the somatic level. Memory is unreliable at best, but the body holds the key to what is unfinished and needing to heal. We focus on allowing those physiological responses to unfold, which makes room for the body to organically return to homeostasis.
 
In the SE model, we consider our work to focus on resolving the strategies for coping with nervous system dysregulation. This dysregulation can occur as the result of trauma, but may occur even in the absence of specific traumatic events—early attachment issues, for example. What is primary to us is to restore the nervous system to a natural state of regulation. To this end, SE is well integrated with many modalities of therapy, adding richness and depth to other methods that may have a more primary focus on the emotional or cognitive aspects of experience. What is most important about the SE way of working with a client is our focus on the physiological, the sensations, the body.
 
A wealth of information can be found at the Foundation for Human Enrichment web site. A comprehensive SE Training program is available for those seeking to learn how to apply this method in their work. A vivid demonstration of SE is seen in Resolving Trauma in Psychotherapy: A Somatic Approach.

“When I’m good, I’m very good, but when I’m bad I’m better”: A New Mantra for Psychotherapists

Posted on by rezendevknowfully.com
Current estimates suggest that nearly 50 percent of therapy clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies. Barry Duncan and Scott Miller provide a comprehensive summary of the Outcome-Informed, Client-Directed approach and a detailed, practical overview of its application in clinical practice. Through case examples they demonstrate how most practitioners can increase their therapeutic effectiveness substantially through accurate identification of those clients who are not responding, and addressing the lack of change in a way that keeps clients engaged in treatment and forges new directions.

Introduction

At first blush, Mae West's famous words 'When I'm good, I'm very good, but when I'm bad I'm better' hardly seem like a guide for therapists to live by—but, as it turns out, they could be. Research demonstrates consistently that who the therapist is accounts for far more of the variance of change (6 to 9 percent) than the model or technique administered (1 percent). In fact, therapist effectiveness ranges from a paltry 20 percent to an impressive 70 percent. A small group of clinicians—sometimes called 'supershrinks'—obtain demonstrably superior outcomes in most of their cases, while others fall predictably on the less-exalted sections of the bell-shaped curve. However, most practitioners can join the ranks of supershrinks, or at least increase their therapeutic effectiveness substantially.
 
Consider Matt, a twenty-something software whiz who was on the road frequently to trouble-shoot customer problems. Matt loved his job but travelling was an ordeal—not because of flying but because of another, far more embarrassing problem. Matt was long past feeling frustrated about standing and standing in public restrooms trying to 'go.' What started as a mild discomfort and inconvenience easily solved by repeated restroom visits had progressed to full-blown anxiety attacks, an excruciating pressure, and an intense dread before each trip. Feeling hopeless and demoralized, Matt considered changing jobs but as a last resort decided instead to see a therapist.
 
Matt liked the therapist and it felt good finally to tell someone about the problem. The therapist worked with Matt to implement relaxation and self-talk strategies. Matt practiced in session and tried to use the ideas on his next trip, but still no 'go.' The problem continued to get worse. Now three sessions in, Matt was at significant risk for a negative outcome—either dropping out or continuing in therapy without benefit.
 
We have all encountered clients unmoved by treatment. Therapists often blame themselves. The overwhelming majority of psychotherapists, as cliched as it sounds, want to be helpful. Many of us answered "I want to help people" on graduate school applications as the reason we chose to be therapists. Often, some well-meaning person dissuaded us from that answer because it didn't sound sophisticated or appeared too 'co-dependent.' Such aspirations, we now believe, are not only noble but can provide just what is needed to improve clinical effectiveness. After all, there is not much financial incentive for doing better therapy—we don't do this work because we thought we would acquire the lifestyles of the rich and famous.
 
Unfortunately, the altruistic desire to be helpful sometimes leads us to believe that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. “Amid explanations and remedies aplenty, therapists search courageously for designer explanations and brand-name miracles, but continue to observe that clients drop out, or even worse, continue without benefit.” Current estimates suggest that nearly 50 percent of our clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies.
 
So what can we do to channel our healthy desire to be helpful? If we listen to the lessons of the top performers, the first thing we should do is step outside of our comfort zones and push the limits of our current performance—to identify accurately those clients not responding to our therapeutic business as usual, and address the lack of change in a way that keeps clients engaged in treatment and forges new directions.
 
To recapture those clients who slip through the cracks, we need to embrace what is known about change: Many studies reveal that the majority of clients experience change in the first six visits—clients reporting little or no change early on tend to show no improvement over the entire course of therapy, or wind up dropping out. Early change, in other words, predicts engagement in therapy and ongoing benefit. This doesn't mean that a client is 'cured' or the problem is totally resolved, but rather that the client has a subjective sense that things are getting better. And second, a mountain of studies have long demonstrated another robust predictor—that reliable, tried-and-true but taken-for-granted old friend—the therapeutic alliance. Clients who highly rate the relationship with their therapist tend to be those clients who stick around in therapy and benefit from it.
 
Next we need to measure those known predictors in a systematic way with reliable and valid instruments. So instead of regarding the first few therapy sessions as a 'warm-up' period or a chance to try out the latest technique, we engage the client in helping us judge whether therapy is providing benefit. Obtaining feedback on standardized measures about success or failure during those initial meetings provides invaluable information about the match between ourselves, our approach, and the client—enabling us to know when we are bad, so we can be even better. The only way we can improve our outcomes is to know, very early on, when the client is not benefiting—we need something akin to an early warning signal.
 
Using standardized measures to monitor outcome may make your skin crawl and bring to mind torture devices like the Rorschach or MMPI. But the forms for these measures are not used to pass judgment, diagnose or unravel the mysteries of the human psyche. Rather, these measures invite clients into the inner circle of mental health and substance abuse services—they involve clients collaboratively in monitoring progress toward their goals and the fit of the services they are receiving, and amplify their voices in any decisions about their care.

The Outcome Rating Scale (ORS)

You might also think that the last thing you need is to add more paperwork to your practice. But finding out who is and isn't responding to therapy need not be cumbersome. In fact, it only takes a minute. Dissatisfied with the complexity, length, and user- unfriendliness of existing outcome measures, we developed the Outcome Rating Scale (ORS) as a brief clinical alternative. The ORS (child measures also available) and all the measures discussed here are available for free download at talkingcure.com. The ORS assesses three dimensions:
  1. Personal or symptomatic distress (measuring individual well-being)
  2. Interpersonal well-being (measuring how well the client is getting along in intimate relationships)
  3. Social role (measuring satisfaction with work/school and relationships outside of the home)
Changes in these three areas are considered widely to be valid indicators of successful outcome. The ORS simply translates these three areas and an overall rating into a visual analog format of four 10-cm lines, with instructions to place a mark on each line with low estimates to the left and high to the right. The four 10-cm lines add to a total score of 40. The score is simply the summation of the marks made by the client to the nearest millimeter on each of the four lines, measured by a centimeter ruler or available template. A score of 25, the clinical cutoff, differentiates those who are experiencing enough distress to be in a helping relationship from those who are not. Because of its simplicity, ORS feedback is available immediately for use at the time the service is delivered. Rated at an eighth-grade reading level, the ORS is understood easily and clients have little difficulty connecting it their day-to-day lived experience.
 
Matt completed the ORS before each session. He entered therapy with a score of 18, about average for those attending outpatient settings, but continued to hover at that score. At the third session, when the ORS reflected no change, it was not front-page news to Matt. But a different process ensued. In the same spirit of collaboration as the assessment process, Matt and his therapist brainstormed ideas, a free-for-all of unedited speculations and suggestions of alternatives, from changing nothing about the therapy to taking medication to shifting treatment approaches. During this open exchange Matt intimated that he was beginning to feel angry about the whole thing—real angry. The therapist noticed that when Matt worked himself up to a good anger—about how his problem interfered with his work and added a huge hassle in any extended situation away from his own bathroom—that he became quite animated, a stark contrast to the passively resigned person that had characterized their previous sessions. One of them, which one remains a mystery, mentioned the words 'pissed off' and both broke into a raucous laughter. Subsequently, the therapist suggested that instead of responding with hopelessness when the problem occurred, that Matt work himself up to a good anger—about how this problem made his life miserable. Matt added (he was a rock-and-roll buff) that he could also sing the Tom Petty song "Won't Back Down" during his tirade at the toilet. Matt allowed himself, when standing in front of the urinal to become incensed—downright 'pissed off,' and amused. And he started to go.
 
This process, the delightful creative energy that emerges from the wonderful interpersonal event we call therapy, could have happened to any therapist working with Matt. The difference is that the use of the outcome measure spotlighted the lack of change and made it impossible to ignore. The ORS brought the risk of a negative outcome front and center and allowed the therapist to enact the second characteristic of supershrinks, to be exceptionally alert to the risk of dropout and treatment failure. In the past, we might have continued with the same treatment for several more sessions, unaware of its ineffectiveness or believing (hoping, even praying) that our usual strategies would eventually take hold, but the reliable outcome data pushed us to explore different treatment options by the end of the third visit.
 
Pushing the limits of one's performance requires monitoring the fit of your service with the client's expectations about the alliance. The ongoing assessment of the alliance enables therapists to identify and correct areas of weakness in the delivery of services before they exert a negative effect on outcome.
 

The Session Rating Scale (SRS)

Research shows repeatedly that clients' ratings of the alliance are far more predictive of improvement than the type of intervention or the therapist's ratings of the alliance. Recognizing these much-replicated findings, we developed the Session Rating Scale (SRS) as a brief clinical alternative to longer research-based alliance measures to encourage routine conversations with clients about the alliance. The SRS also contains four items. First, a relationship scale rates the meeting on a continuum from "I did not feel heard, understood, and respected" to "I felt heard, understood, and respected." Second is a goals and topics scale that rates the conversation on a continuum from "We did not work on or talk about what I wanted to work on or talk about" to "We worked on or talked about what I wanted to work on or talk about." Third is an approach or method scale (an indication of a match with the client's theory of change) requiring the client to rate the meeting on a continuum from "The approach is not a good fit for me" to "The approach is a good fit for me." Finally, the fourth scale looks at how the client perceives the encounter in total along the continuum: "There was something missing in the session today" to "Overall, today's session was right for me."
 
The SRS simply translates what is known about the alliance into four visual analog scales, with instructions to place a mark on a line with negative responses depicted on the left and positive responses indicated on the right. The SRS allows alliance feedback in real time so that problems may be addressed. Like the ORS, the instrument takes less than a minute to administer and score. The SRS is scored similarly to the ORS, by adding the total of the client's marks on the four 10-cm lines. The total score falls into three categories:
  • SRS score between 0–34 reflects a poor alliance,
  • SRS Score between 35–38 reflects a fair alliance,
  • SRS Score between 39–40 reflects a good alliance.

The SRS allows the implementation of the final lesson of the supershrinks—seek, obtain, and maintain more consumer engagement. Clients drop out of therapy for two reasons: one is that therapy is not helping (hence monitoring outcome) and the other is alliance problems—they are not engaged or turned on by the process. The most direct way to improve your effectiveness is simply to keep people engaged in therapy.

 
An alliance problem that occurs frequently emerges when client's goals do not fit our own sensibilities about what they need. This may be particularly true if clients carry certain diagnoses or problem scenarios. Consider 19-year-old Sarah, who lived in a group home and received social security disability for mental illness. Sarah was referred for counseling because others were concerned that she was socially withdrawn. Everyone was also worried about Sarah's health because she was overweight and spent much of her time watching TV and eating snack foods.
 
In therapy Sarah agreed that she was lonely, but expressed a desire to be a Miami Heat cheerleader. Perhaps understandably, that goal was not taken seriously. After all, Sarah had never been a cheerleader, was 'schizophrenic,' and was not exactly in the best of shape. So no one listened, or even knew why Sarah had such an interesting goal. And the work with Sarah floundered. She spoke rarely and gave minimal answers to questions. In short, Sarah was not engaged and was at risk for dropout or a negative outcome.
 
The therapist routinely gave Sarah the SRS and she had reported that everything was going swimmingly, although the goals scale was an 8.7 out of 10, instead of a 9 or above out of 10 like the rest.
 
Sometimes it takes a bit more work to create the conditions that allow clients to be forthright with us, to develop a culture of feedback in the room. The power disparity combined with any socioeconomic, ethnic, or racial differences make it difficult to tell authority figures that they are on the wrong track. Think about the last time you told your doctor that he or she was not performing well. Clients, however, will let us know subtly on alliance measures far before they will confront us directly.
 
At the end of the third session, the therapist and Sarah reviewed her responses on the SRS. Did she truly feel understood? Was the therapy focused on her goals? Did the approach make sense to her? Such reviews are helpful in fine-tuning the therapy or addressing problems in the therapeutic relationship that have been missed or gone unreported. Sarah, when asked the question about goals, all the while avoiding eye contact and nearly whispering, repeated her desire to be a Miami Heat cheerleader.
 
The therapist looked at the SRS and the lights came on. The slight difference on the goals scale told the tale. When the therapist finally asked Sarah about her goal, she told the story of growing up watching Miami Heat basketball with her dad who delighted in Sarah's performance of the cheers. Sarah sparkled when she talked of her father, who passed away several years previously, and the therapist noted that it was the most he had ever heard her speak. He took this experience to heart and often asked Sarah about her father. The therapist also put the brakes on his efforts to get Sarah to socialize or exercise (his goals), and instead leaned more toward Sarah's interest in cheerleading. Sarah watched cheerleading contests regularly on ESPN and enjoyed sharing her expertise. She also knew a lot about basketball.
 
Sarah's SRS score improved on the goal scale and her ORS score increased dramatically. After a while, Sarah organized a cheerleading squad for her agency's basketball team who played local civic organizations to raise money for the group home. Sarah's involvement with the team ultimately addressed the referral concerns about her social withdrawal and lack of activity. The SRS helps us take clients and their engagement more seriously, like the supershrinks do. Walking the path cut by client goals often reveals alternative routes that would have never been discovered otherwise.
 
Providing feedback to clinicians on the clients' experience of the alliance and progress has been shown to result in significant improvements in both client retention and outcome. “We found that clients of therapists who opted out of completing the SRS were twice as likely to drop out and three times more likely to have a negative outcome.” In the same study of over 6000 clients, effectiveness rates doubled. As incredible as the results appear, they are consistent with findings from other researchers.
 
In a 2003 meta-analysis of three studies, Michael Lambert, a pioneer of using client feedback, reported that those helping relationships at risk for a negative outcome which received formal feedback were, at the conclusion of therapy, better off than 65 percent of those without information regarding progress. Think about this for a minute. Even if you are one of the most effective therapists, for every cycle of 10 clients you see, three will go home without benefit. Over the course of a year, for a therapist with a full caseload, this amounts to a lot of unhappy clients. This research shows that you can recover a substantial portion of those who don't benefit by first identifying who they are, keeping them engaged, and tailoring your services accordingly.
 

The Nuts and Bolts

Collecting data on standardized measures and using what we call 'practice-based evidence' can improve your effectiveness substantially. "Wait a minute," you say, "this sounds a lot like research!" Given the legionary schism between research and practice, sometimes getting therapists to do the measures is indeed a tall order because it does sound a lot like the 'R' word.
 
A story illustrates the sentiments that many practitioners feel about research. Two researchers were attending an annual conference. Although enjoying the proceedings, they decided to find some diversion to combat the tedium of sitting all day and absorbing vast amounts of information. They settled on a hot air balloon ride and were quite enjoying themselves until a mysterious fog rolled in. Hopelessly lost, they drifted for hours until a clearing in the fog appeared finally and they saw a man standing in an open field. Joyfully, they yelled down at the man, "Where are we?" The man looked at them, and then down at the ground, before turning a full 360 degrees to survey his surroundings. Finally, after scratching his beard and what seemed to be several moments of facial contortions reflecting deep concentration, the man looked up and said, "You are above my farm."
 
The first researcher looked at the second researcher and said, "That man is a researcher—he is a scientist!" To which the second researcher replied, "Are you crazy, man? He is a simple farmer!" "No," answered the first researcher emphatically, "that man is a researcher and there are three facts that support my assertion: First, what he said was absolutely 100% accurate; second, he addressed our question systematically through an examination of all of the empirical evidence at his disposal, and then deliberated carefully on the data before delivering his conclusion; and finally, the third reason I know he is a researcher is that what he told us is absolutely useless to our predicament."
 
But unlike much of what is passed off as research, the systematic collection of outcome data in your practice is not worthless to your predicament. It allows you the luxury of being useful to clients who would otherwise not be helped. And it helps you to get out of the way of those clients you are not helping, and connecting them to more likely opportunities for change.
 
First, collaboration with clients to monitor outcome and fit actually starts before formal therapy. This means that they are informed when scheduling the first contact about the nature of the partnership and the creation of a 'culture of feedback' in which their voice is essential.
 
"I want to help you reach your goals. I have found it important to monitor progress from meeting to meeting using two very short forms. Your ongoing feedback will tell us if we are on track, or need to change something about our approach, or include other resources or referrals to help you get what you want. I want to know this sooner rather than later, because if I am not the person for you, I want to move you on quickly and not be an obstacle to you getting what you want. Is that something you can help me with?"
 
We have never had anyone tell us that keeping track of progress is a bad idea. There are five steps to using practice based evidence to improve your effectiveness.
 

Step One: Introducing the ORS in the First Session

The ORS is administered prior to each meeting and the SRS toward the end. In the first meeting, the culture of feedback is continually reinforced. It is important to avoid technical jargon, and instead explain the purpose of the measures and their rationale in a natural commonsense way. Just make it part of a relaxed and ordinary way of having conversations and working. The specific words are not important—there is no protocol that must be followed. This is a clinical tool! Your interest in the client's desired outcome speaks volumes about your commitment to the client and the quality of service you provide.
 
"Remember our earlier conversation? During the course of our work together, I will be giving you two very short forms that ask how you think things are going and whether you think things are on track. To make the most of our time together and get the best outcome, it is important to make sure we are on the same page with one another about how you are doing, how we are doing, and where we are going. We will be using your answers to keep us on track. Will that be okay with you?"
 

Step Two: Incorporating the ORS in the first session

The ORS pinpoints where the client is and allows a comparison for later sessions. Incorporating the ORS entails simply bringing the client's initial and subsequent results into the conversation for discussion, clarification and problem solving. The client's initial score on the ORS is either above or below the clinical cutoff. You need only to mention the client scores as it relates to the cutoff. Keep in mind that the use of the measures is 100-percent transparent. There is nothing that they tell you that you cannot share with the client. It is their interpretation that ultimately counts.
 
"From your ORS it looks like you're experiencing some real problems." Or: "From your score, it looks like you're feeling okay." "What brings you here today?" Or: "Your total score is 15—that's pretty low. A score under 25 indicates people who are in enough distress to seek help. Things must be pretty tough for you. Does that fit your experience? What's going on?"
 
"The way this ORS works is that scores under 25 indicate that things are hard for you now or you are hurting enough to bring you to see me. Your score on the individual scale indicates that you are really having a hard time. Would you like to tell me about it?"
 
Or if the ORS is above 25: "Generally when people score above 25, it is an indication that things are going pretty well for them. Does that fit your experience? It would be really helpful for me to get an understanding of what it is that brought you here now."
 
Because the ORS has face validity, clients usually mark the scale the lowest that represents the reason they are seeking therapy, and often connect that reason to the mark they've made without prompting from the therapist. For example, Matt marked the Individual scale the lowest with the Social scale coming in a close second. As he was describing his problem in public restrooms, he pointed to the ORS and explained that this problem accounted for his mark. Other times, the therapist needs to clarify the connection between the client's descriptions of the reasons for services and the client's scores. The ORS makes no sense unless it is connected to the described experience of the client's life. This is a critical point because clinician and client must know what the mark on the line represents to the client and what will need to happen for the client to both realize a change and indicate that change on the ORS.
 
At some point in the meeting, the therapist needs only to pick up on the client's comments and connect them to the ORS:
 
"Oh, okay, it sounds like dealing with the loss of your brother (or relationship with wife, sister's drinking, or anxiety attacks, etc.) is an important part of what we are doing here. Does the distress from that situation account for your mark here on the individual (or other) scale on the ORS? Okay, so what do you think will need to happen for that mark to move just one centimeter to the right?"
 
The ORS, by design, is a general outcome instrument and provides no specific content other than the three domains. The ORS offers only a bare skeleton to which clients must add the flesh and blood of their experiences, into which they breathe life with their ideas and perceptions. At the moment in which clients connect the marks on the ORS with the situations that are distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool.
 

Step Three: Introducing the SRS

The SRS, like the ORS, is best presented in a relaxed way that is integrated seamlessly into your typical way of working. The use of the SRS continues the culture of client privilege and feedback, and opens space for the client's voice about the alliance. The SRS is given at the end of the meeting, but leaving enough time to discuss the client's responses.
 
"Let's take a minute and have you fill out the form that asks for your opinion about our work together. It's like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. Is that okay with you?"
 

Step Four: Incorporating the SRS

Because the SRS is easy to score and interpret, you can do a quick visual check and integrate it into the conversation. If the SRS looks good (score more than 9 cm on any scale), you need only comment on that fact and invite any other comments or suggestions. If the client marks any scales lower than 9 cm, you should definitely follow up. Clients tend to score all alliance measures highly, so the practitioner should address any hint of a problem. Anything less than a total score of 36 might signal a concern, and therefore it is prudent to invite clients to comment. Keep in mind that a high rating is a good thing, but it doesn't tell you very much. Always thank the client for the feedback and continue to encourage their open feedback. Remember that unless you convey you really want it, you are unlikely to get it.
 
And know for sure that there is no 'bad news' on these forms. Your appreciation of any negative feedback is a powerful alliance builder. In fact, alliances that start off negatively but result in your flexibility to client input tend to be very predictive of a positive outcome. When you are bad, you are even better! In general, a score:
  • that is poor and remains poor predicts a negative outcome,
  • that is good and remains good predicts a positive outcome,
  • that is poor or fair and improves predicts a positive outcome even more,
  • that is good and decreases is predictive of a negative outcome.
The SRS allows the opportunity to fix any alliance problems that are developing and shows that you do more than give lip service to honoring the client's perspectives.
 
"Let me just take a look at this SRS—it's like a thermometer that takes the temperature of our meeting here today. Great, looks like we are on the same page, that we are talking about what you think is important and you believe today's meeting was right for you. Please let me know if I get off track, because letting me know would be the biggest favor you could do for me."
 
"Let me quickly look at this other form here that lets me know how you think we are doing. Okay, seems like I am missing the boat here. Thanks very much for your honesty and giving me a chance to address what I can do differently. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here?"
 
Graceful acceptance of any problems and responding with flexibility usually turns things around. Again, clients reporting alliance problems that are addressed are far more likely to achieve a successful outcome—up to seven times more likely! Negative scores on the SRS, therefore, are good news and should be celebrated. Practitioners who elicit negative feedback tend to be those with the best effectiveness rates. Think about it—it makes sense that if clients are comfortable enough with you to express that something isn't right, then you are doing something very right in creating the conditions for therapeutic change.
 

Step Five: Checking for change in subsequent sessions

With the feedback culture set, the business of practice-based evidence can begin, with the client's view of progress and fit really influencing what happens. Each subsequent meeting compares the current ORS with the previous one and looks for any changes. The ORS can be made available in the waiting room or via electronic software (ASIST) and web systems (MyOutcomes.com). Many clients will complete the ORS (some will even plot their scores on provided graphs) and greet the therapist already discussing the implications. Using a scale that is simple to score and interpret increases client engagement in the evaluation of the services. Anything that increases participation is likely to have a beneficial impact on outcome.
 
The therapist discusses if there is an improvement (an increase in score), a slide (a decrease in score), or no change at all. The scores are used to engage the client in a discussion about progress, and more importantly, what should be done differently if there isn't any.
 
"Your marks on the personal well-being and overall lines really moved—about 4 cm to the right each! Your total increased by 8 points to 29 points. That's quite a jump! What happened? How did you pull that off? Where do you think we should go from here?"
 
If no change has occurred, the scores invite an even more important conversation.
 
"Okay, so things haven't changed since the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say 'when?' "
 
The idea is to involve the client in monitoring progress and the decision about what to do next. The discussion prompted by the ORS is repeated in all meetings, but later ones gain increasing significance and warrant additional action. We call these later interactions either checkpoint conversations or last-chance discussions. In a typical outpatient setting, checkpoint conversations are conducted usually at the third meeting and last-chance discussions are initiated in the sixth session. This is simply saying that based on over 300,000 administrations of the measures, by the third encounter most clients who do receive benefit from services usually show some benefit on the ORS; and if change is not noted by meeting three, then the client is at a risk for a negative outcome. Ditto for session six except that everything just mentioned has an exclamation mark. Different settings could have different checkpoints and last-chance numbers. Determining these highlighted points of conversation requires only that you collect the data. The calculations are simple and directions can be found in our book, The Heroic Client. Establishing these two points helps evaluate whether a client needs a referral or other change based on a typical successful client in your specific setting. The same thing can be accomplished more precisely by available software or web-based systems that calculate the expected trajectory or pattern of change based on our data base of ORS administrations. These programs compare a graph of the client's session-by-session ORS results to the expected amount of change for clients in the data base with the same intake score, serving as a catalyst for conversation about the next step in therapy.
 
If change has not occurred by the checkpoint conversation, the therapist responds by going through the SRS item by item. Alliance problems are a significant contributor to a lack of progress. Sometimes it is useful to say something like, "It doesn't seem like we are getting anywhere. Let me go over the items on this SRS to make sure you are getting exactly what you are looking for from me and our time together." Going through the SRS and eliciting client responses in detail can help the practitioner and client get a better sense of what may not be working. Sarah, the woman who aspired to be a Miami Heat cheerleader, exemplifies this process.
 
Next, a lack of progress at this stage may indicate that the therapist needs to try something different. This can take as many forms as there are clients: inviting others from the client's support system, using a team or another professional, a different approach; referring to another therapist, religious advisor, or self-help group—whatever seems to be of value to the client. Any ideas that surface are then implemented, and progress is monitored via the ORS. Matt and the idea of encouraging his anger illustrate this kind of discussion.
 

The Importance of Referrals

If the therapist and client have implemented different possibilities and the client is still without benefit, it is time for the last-chance discussion. As the name implies, there is some urgency for something different because most clients who benefit have already achieved change by this point, and the client is at significant risk for a negative conclusion. A metaphor we like is that of the therapist and client driving into a vast desert and running on empty, when a sign appears on the road that says 'last chance for gas.' The metaphor depicts the necessity of stopping and discussing the implications of continuing without the client reaching a desired change.
 
This is the time for a frank discussion about referral and other available resources. If the therapist has created a feedback culture from the beginning, then this conversation will not be a surprise to the client. There is rarely justification for continuing work with clients who have not achieved change in a period typical for the majority of clients seen by a particular practitioner or setting.
 
Why? Because research shows no correlation between a therapy with a poor outcome and the likelihood of success in the next encounter. Although we've found that talking about a lack of progress turns most cases around, we are not always able to find a helpful alternative.
 
“Where in the past we might have felt like failures when we weren't being effective with a client, we now view such times as opportunities to stop being an impediment to the client and their change process.” Now our work is successful when the client achieves change and when, in the absence of change, we get out of their way. We reiterate our commitment to help them achieve the outcome they desire, whether by us or by someone else. When we discuss the lack of progress with clients, we stress that failure says nothing about them personally or their potential for change. Some clients terminate and others ask for a referral to another therapist or treatment setting. If the client chooses, we will meet with her or him in a supportive fashion until other arrangements are made. Rarely do we continue with clients whose ORS scores show little or no improvement by the sixth or seventh visit.
 
Ending with clients who are not making progress does not mean that all therapy should be brief. On the contrary, our research and the “findings of virtually every study of change in therapy over the last 40 years provide substantial evidence that more therapy is better than less therapy for those clients who make progress early in treatment” and are interested in continuing. When little or no improvement is forth coming, however, this same data indicates that therapy should, indeed, be as brief as possible. Over time, we have learned that explaining our way of working and our beliefs about therapy outcomes to clients avoids problems if therapy is unsuccessful and needs to be terminated.
 
Barry Duncan writes: But it can be hard to believe that stopping a great relationship is the right thing to do.
 
Alina sought services because she was devastated and felt like everything important to her had been savagely ripped apart—because it had. She worked her whole life for but one goal, to earn a scholarship to a prestigious Ivy-league university. She was captain of the volleyball team, commanded the first position on the debating team, and was valedictorian of her class. Alina was the pride of her Guatemalan community—proof positive of the possibilities her parents always envisioned in the land of opportunity. Alina was awarded a full ride in minority studies at Yale University. But this Hollywood caliber story hit a glitch. Attending her first semester away from home and the insulated environment in which she excelled, Alina began hearing voices.
 
She told a therapist at the university counseling center and before she knew it she was whisked away to a psychiatric unit and given antipsychotic medications. Despondent about the implications of this turn of events, Alina threw herself down a stairwell, prompting her parents to bring her home. Alina returned home in utter confusion, still hearing voices, and with a belief that she was an unequivocal failure to herself, her family, and everyone else in her tightly knit community whose aspirations rode on her shoulders.
 
Serendipity landed Alina in my office. I was the twentieth therapist the family called and the first who agreed to see Alina without medication. Alina's parents were committed to honor her preference to not take medication. We were made for each other and hit it off famously. I loved this kid. I admired her intelligence and spunk in standing up to psychiatric discourse and the broken record of medication. I couldn't wait to be useful to Alina and get her back on track. When I administered the ORS, Alina scored a 4, the lowest score I'd ever had.
 
We discussed her total demoralization and how her episodes of hearing voices and confusion led to the events that took everything she had always dreamed of from her—the life she had worked so hard to prepare for. I did what I usually did that is helpful—I listened, I commiserated, I validated, and I worked hard to recruit Alina's resilience to begin anew. But nothing happened.
 
By session three, Alina remained unchanged in the face of my best efforts. Therapy was going nowhere and I knew it because the ORS makes it hard to ignore—that score of 4 was a rude reminder of just how badly things were going.
 
At the checkpoint session, I went over the SRS with her, and unlike many clients, Alina was specific about what was missing and revealed that she wanted me to be more active, so I was. She wanted ideas about what to do about the voices, so I provided them—thought stopping, guided imagery, content analysis. But, no change ensued and she was increasingly at risk for a negative outcome. Alina told me she had read about hypnosis on the internet and thought that might help. Since I had been around in the '80s and couldn't escape that time without hypnosis training, I approached Alina from a couple of different hypnotic angles—offering both embedded suggestions as well as stories intended to build her immunity to the voices. She responded with deep trances and gave high ratings on the SRS. But the ORS remained a paltry 4.
 
At the last-chance conversation, I brought up the topic of referral but we settled instead on a consult from a team (led by Jacqueline Sparks). Alina, again, responded well, and seemed more engaged than I had noticed with me—she rated the session the highest possible on the SRS. The team addressed topics I hadn't, including differentiation from her family, as well as gender and ethnic issues. Alina and I pursued the ideas from the team for a couple more sessions. But her ORS score was still a 4.
 
Now what? We were in session nine, well beyond how clients typically change in my practice. After collecting data for several years, I know that 75 percent of clients who benefit from their work with me show it by the third session; a full 98 per cent of my clients who benefit do it by the sixth session. So is it right that I continue with Alina? Is it even ethical?
 
Despite our mutual admiration society, it wasn't right to continue. A good relationship in the absence of benefit is a good definition of dependence. So I shared my concern that her dream would be in jeopardy if she continued seeing me. I emphasized that the lack of change had nothing to do with either of us, that we had both tried our best, and for whatever reason, it just wasn't the right mix for change. We discussed the possibility that Alina see someone else. If you watch the video, you would be struck, as many are, by the decided lack of fun Alina and I have during this discussion.
 
Finally, after what seemed like an eternity, including Alina's assertion that she wanted to keep seeing me, we started to talk about who she might see. She mentioned she liked someone from the team, and began seeing our colleague Jacqueline Sparks.
 
By session four, Alina had an ORS score of 19 and enrolled to take a class at a local university. Moreover, she continued those changes and re-enrolled at Yale the following year with her scholarship intact! When I wrote a required recommendation letter for the Dean, I administered the ORS to Alina and she scored a 29. By my getting out of her way and allowing her and myself to 'fail successfully,' Alina was given another opportunity to get her life back on track—and she did. Alina and Jacqueline, for reasons that escape us even after pouring over the video, just had the right chemistry for change.
 
This was a watershed client for me. Although I believed in practice-based evidence, especially how it puts clients center stage and pushes me to do something different when clients don't benefit, I always struggled with those clients who did not benefit, but who wanted to continue with me nevertheless. This was more difficult when I really liked the client and had become personally invested in them benefiting. Alina awakened me to the pitfalls of such situations and showed a true value-added dimension to monitoring outcome—namely the ability to fail successfully with our clients. Alina was the kind of client I would have seen forever. I cared deeply about her and believed that surely I could figure out something eventually.
 
But such is the thinking that makes 'chronic' clients—an inattention to the iatrogenic effects of the continuation of therapy in the absence of benefit. Therapists, no matter how competent or trained or experienced, cannot be effective with everyone, and other relational fits may work out better for the client. Although some clients want to continue in the absence of change, far more do not want to continue when given a graceful way to exit. The ORS allows us to ask ourselves the hard questions when clients are not, by their own ratings, seeing benefit from services. The benefits of increased effectiveness of my work, and feeling better about the clients that I am not helping, have allowed me to leave any squeamishness about forms far behind.
 
Practice-based evidence will not help you with the clients you are already effective with; rather, it will help you with those who are not benefiting by enabling an open discussion of other options and, in the absence of change, the ability to honorably end and move the client on to a more productive relationship. The basic principle behind this way of working is that our day-to-day clinical actions are guided by reliable, valid feedback about the factors that account for how people change in therapy. These factors are the client's engagement and view of the therapeutic relationship, and—the gold standard—the client's report of whether change occurs. Monitoring the outcome and the fit of our services helps us know that when we are good, we are very good, and when we are bad, we can be even better.

Psychotherapy Isn’t What You Think: Bringing the Psychotherapeutic Engagement into the Living Moment

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Prologue

Psychotherapy isn't what you think. It isn't a healing of an illness. It isn't guidance from a wise counselor. It isn't the mutual sharing of good friends. It isn't learning esoteric knowledge. It isn't being shown the error of one's ways. It isn't finding a new religion. Psychotherapy isn't what you think.

Psychotherapy is not what you think. It surprises many people because it is not primarily about your childhood . . . or about what has hurt or traumatized you . . . or about the germs in your body . . . or about destructive habits you've acquired . . . or about negative attitudes you carry . . . .

Psychotherapy is not what you think. It is about how you think. It calls attention to unrecognized assumptions in how you think. It makes a distinction between what you think about and how you do that thinking. It is less concerned with looking for causes to explain what you do and more concerned with discovering patterns in the meanings you make of what you're doing.

Psychotherapy is about how you think. It is about how you live with your emotions. It is about the perspectives you bring to relating with the people who matter to you. It is about what you aspire to in your life and how you may unwittingly make it harder for yourself to reach those goals. It is about being helped to see that the change you seek is already latent within you. It is coming to recognize and appreciate the spark of something eternal that is your core.

Psychotherapy is not what you think; it is about how you live with yourself right now.

Psychotherapy Freshens How We Perceive Our Living

. . . It is appropriate to take several steps back in order to view in broader perspective what it is that is the focus of our concern. When we do so we are demonstrating the very theme we are expressing: Life is lived as a perceptual experience. How we "see" or define our own nature and the nature of the world in which we find ourselves is a crucial element in determining what our lives will mean to us and to those with whom we share this epoch of living.

The opportunity, necessity, and challenge of living is that each of us must create and live out a life. Ultimately this is an individual responsibility—even though that often may not seem to be the case. Many influences press us to disavow or, at least, to try to delegate this responsibility.

Recognition of this basic life truth of our ultimate self-responsibility is sometimes misunderstood as a kind of "blaming the victim" philosophy and in other instances is thought to be an absurd "Pollyannaism" which promises that anyone can do anything if only he will set his mind to it. Of course, neither of these is sensible, and certainly neither is accepted by the stance here presented.

It is obviously and irrevocably true that we live in a multifaceted reality which profoundly affects what we experience and what opportunities and obstacles we encounter in carrying out this basic responsibility for our lives.

When and where one is born, whether female or male, healthy or ailing, intelligent or of limited potential, into what sort of family, society, and times; and much else influence our lives' courses. Yet each of these factors—and the many others, including some of which we are only partially aware—open out into further arrays.

Literature, both popular and technical, provides many accounts of individuals who overcame crippling environmental and chance-inflicted handicaps to live rich and contributing lives. To be sure, often such stories also recognize how exceptional native talents were called into action and in turn facilitated the exceptional outcomes. But it would be naive to attempt to so dismiss all such instances as simply products of random gene combinations. Indeed there is the real possibility that the exceptional talents were in some measure the products of human will as it confronted those very handicaps.

Candidly, almost any of us who soberly examines his own history is likely to discover occasions on which he failed to use his powers effectively and other times when he stretched to go beyond what were his usual life patterns. Popular idiom says it, "If life hands you a lemon, make lemonade."

Yet by no means does this homily assure a happy ever-after outcome. We simply don't know the stories of unnumbered men and women of great potential who were overwhelmed by circumstances and never realized their potential.

The Therapist's Mission

Our work, as we view it in this book, is to engage with the client's way of grappling with his life, or in other words, with the patterns through which the client seeks to be safe, fulfilled, in relation. "To engage" not to learn about them; "engage" signals a more experiential process. That, in turn, implies that the therapist cannot simply be a detached observer but needs lived experience of how her client grapples with her life.

Those patterns constitute the client's implicit conception of his own nature, powers, vulnerabilities, and all else that is implicit in his way of experiencing his own being and employing his powers in life—i.e., the client's self-and-world construct system as it is structured to deal with possibilities, hazards, resources, and much more.

What underlies this stance is the recognition that the self is always defined in terms of its interaction with the environing world, and the world is always perceived in terms of its actual or potential effects on the self.

Another aspect of this conception needs to be made explicit: We are speaking here of perceptions, of how the self and its attributes and the world and its many aspects are perceived. Of course, perception here does not mean only visual or even sensory perceptions as independent existents. Although the sensory facets of our perceptions may prove of great importance at times, they always do so in larger contexts.

We live in a perceptual world—that is, in the world which our perception reveals. As we experience our lives we form percepts about this world's elements and aspects. These become de facto definitions, and rightly or wrongly they do much to determine how we will relate to that which they name.

Is the world a safe place? Can a woman deal with this kind of problem as well as would a man? How will this art authority respond to my paintings? Must I cultivate the big shots to get promoted in my job or will doing a good job be enough?

The Omnipresence of Death

The disease which results in 100-percent fatalities is called "Life." Life is lived between the brackets of birth and death, and that very stark reality subtly or openly affects much that we think and do. In earlier years we implicitly claim immortality, but even then the shadow falls from time to time. As we age, that warning is more frequent and demanding.

Death accompanies life day by day, moment by moment. It isn't an event that will occur in the future; it is an actuality in each moment now. Each moment's life lives on the dead corpse of the previous moment. My lover today dies in tomorrow's kiss.

Recognizing this, anticipation, apprehension, remembrance, and regret are appropriate but not if they obscure what is in this present moment. The very fact of ending can give vitality to that which is in fact now and therefore in some measure accessible, and it counsels action rather than delay.

Psychotherapists need to be aware—and to help their clients be aware—that the resistance is an attempt to delay the death of possibilities. Becoming genuinely aware of that inexorable fact may impel one to claim the life of what is immediately possible and avoid the death of inaction.

Searching is the life force (chi) being its own nature. Case formulations can so easily become like butterflies impaled on pins and put in display cases.

Psychotherapy and Changing

It is time to try to bring together the chief elements of the existential-humanistic perspective on life-changing psychotherapy, as I envision it. Other psychotherapists will, of course, have points of difference, and that is as it should be. We are considering an art form, and by its very nature, all art is not to be captured by any one artist. Thus each person must, perforce, produce a masterwork, and no explanations can ease that responsibility.

Effective Ingredients in Psychotherapeutic Change

To begin with a synoptic statement of this existential-humanistic perspective: Essentially and experientially, life is subjective awareness. Without awareness, we are not truly alive. The conditions for which we seek therapy (e.g., anxiety, impulse control, meaninglessness in life, difficulties in relationships) may usefully be thought of as likely to be the products of shrunken and distorted ways of being aware—that is, of being alive.

The range and depth of our awareness constitute the settings of our self-and-world construct systems. When that system is too confining or too poorly corresponding with the consensual world view, we experience anxiety, pain, futility, or other symptoms which may lead us to seek psychotherapy. The task of such therapy is, then, to explore the client's self-and-world construct system and then to facilitate the client's making needed revisions in it.

This system is the way in which the client survives, seeks fulfillment, and avoids harms; yet it is this same system that must be investigated and in which changes must occur as a result of the therapeutic work. Understandably, the work of therapy inevitably encounters resistance from the client's way of being in the world (i.e., that same self-and-world construct system). Thus psychotherapy must encourage and support confrontation with the negative effects of this system while supporting its positive contributions to the client's life.

The two chief ways in which the therapeutic process carries out this work are through (a) intensive attention to the actual way the client explores and utilizes her/his own capacities as manifested in the client's self-presentation in the consultation room and (b) coaching the client to improved skill and range in self-exploration in order to better understand his/her own self-and-world construct system. These tasks are best carried out in a setting of mutual respect and dedication.

This approach to the therapeutic work may be called life-coaching to contrast it with notions of psychotherapy as repair of injuries or curing of diseases. Coaching seeks to increase the positive life skills of the client rather than focusing on negative patterns as such.

Restating the Central Thesis

From Freud on we have been governed by the myth of historic determinism. This implied emphasis on the need to try to discover what happened in the past has brought us to today's information-centered approach. In so much of our work as therapists we tend to be caught up in collecting and disbursing information about the client. Such information may be the client's history, his current concerns, her relationships, and what she hopes to gain from the therapy. Our clients soon get caught up in this information about process.

However, all information is abstracted from the flow of time—i.e., the flow of life. The only truly actual element is the process of the moment in the client; yet clients and therapists have come to discount the momentary and seek "the long view."

What is advanced here is that therapists need to give greater attention to what is, in fact, actual. This means the subjective experience of the client in the moment. This means (in line with Hillman's views) abandoning the notion of finding causes. This means disclosing to the client her/his immediate experience.

I do not reject the notion of historical sources of much in our living, but I do insist that while history equips us with habit systems that can be useful (speech, social intercourse, and much else), these habits are at a level similar to muscle habits—available, repetitive, continually evolving, incompletely conscious, and only semi-voluntary. I can and need at times to adapt or override some habits to type these words, to drive a car, to do most of the physical activities of daily life. I can change and override emotional patterns when I am aware of them in the moment of their activation. However, so many of my emotional habits I only know about incompletely and after their functioning—i.e., as information about myself and information about what is past.

An emotional habit is a set or predisposition to respond in patterned ways to certain situations
What is here proposed is that pointedly identifying in the moment that which is activated but unregarded introduces a new element in one's internal governance. When this is done, a change process is initiated which can have far-reaching results.

What Is Life Coaching?

Life coaching is a mode of psychotherapy. It is, as the name suggests, a combination of concepts and practices through which a trained and dedicated person may provide a facilitating and renewing perspective and experience to another person. The recipient of this aid may be termed a "client" or "patient," but what is important is to emphasize the centrality of this person's own responsibility and self-direction.

Central to this conception is the conviction that many—perhaps most, possibly even all—the distresses which bring people to psychotherapy are at base the product of ineffectual and counterproductive life assumptions and the patterns of action and reaction deriving from them.

A similarly central assumption insists that relief or recovery from such distresses is only to be had when the distressed person comes to fresh perspectives on her/his life—its assumptions, patterns, and internal conflicts.

Reflections About Our Work

  1. The people with whom we are engaged are living all the time they're with us. They bring that-with-which-they-are-not-content to us. They live it out in our offices.
  2. We are not physicians, repairmen/women, or substitutes available to direct others' lives.
  3. We are coaches for those who are not satisfied with their experiences of being alive.
  4. The only change agency which produces lasting results is a change in a person's perception of her/his self and world.
  5. That change will only occur when we help them see more fully how they are living their lives right now, right in the room.
  6. The only reality about one's self is that which actual in this moment. All else is static, is without power, is only information.
  7. Recognition, insight, interpretation, and similar, familiar therapeutic products that are often mistaken for the goal. They are useful to the extent they evoke or express an immediate experiencing.

The Central Drama of Depth Psychotherapy

I will sketch here, in greatly over-simplified terms, the core processes as they are conceived in this orientation. This will permit reviewing key terms. It will also, I hope, foster a more energetic or dynamic sense of the therapeutic engagement than I (quite biasedly) think of as the "whodunit" approach to therapy—i.e., those modes in which primary attention is given to seeking cause-and-effect relations among elements of the client's history and complaints and then to teaching those connections to the client in the hope that the complained-of conditions will be eliminated or at least radically modified.

The basic drama of depth psychotherapy is carried out as a struggle between two opposing forces: on the one hand is a sense of possibility in combination with feelings of concern. These impel each of us forward in all venues of our lives. On the other hand, these positive impulses come up against other subjective elements in the form of forces or structures which seek continuity and predictability. These latter influences can be lumped together under the name resistances. As we explore them further it becomes manifest that they are chiefly expressions of our self-and-world construct systems, the very ways we define our own nature and the nature of the world in which we live. Obviously threats to these definitions, at the most extreme, are experienced as threats to our lives.

What is evident from the foregoing is that our lives are lived at the level of perception. How we see ourselves, our world, our needs, our powers, our potentials—this is the key to our living.

It follows then that psychotherapy must be concerned with perceptions. And, of course, that concern must not be limited solely to the conscious and verbalizable perceptions. Thus in the therapy work described in this book, we attend scrupulously to implicit perceptions as they are manifested in the living moment.

The phrase, "in the living moment," is particularly important. It is no exaggeration to say that the only reality we have is that of this living moment—the moment in which I write these words and the quite other moment in which you read them.

Even were we talking together in the same room, we would not have precisely the same "living moment" because of the multiple and contrasting histories we would bring to our engagement. Another implication of this recognition is that when the client tells about his experience, it is always a different experience than it was when it occurred.

The particular merit of the perspective I'm presenting here is expressed by references to "the actual." What is actual is what is at the very moment; therefore therapeutic attention and efforts need to be focused at the immediate now.

A Semi-Final Recognition

This book has attempted to summarize my thinking and experiencing about psychotherapy as of early 1998. It has fallen short of doing so. Thank the good lord!

Psychotherapy is concerned with life, with living. That means it is concerned with what is going on, what is changing and evolving, what is about to be recognized. A book is much more static than is actual, vital psychotherapy. What I have written has taught me about what I have written. When I rewrite the account of some point I want to express clearly, the point has changed somewhat. When I try to capture the new perception, it has already gone on ahead of me.

That is the way with life. That is the way with our thinking about life. Therefore that is the way with psychotherapy. We are—and we should be—always running to catch up.

You must excuse me now. I've got to hurry to find out what is next.

LIFE ISN'T WHAT YOU THINK*

Life isn't what you think. Life is.

Does the yolk know the shape of the shell?
Does the foaming crest know the power of the wave?

Life isn't what you think.
Life is going on . . . now.
Life is impending even as I write
and as you read.

Life is experiencing, but not experience.
Life isn't what you think.
Life isn't future, past, or even now.
For even that now is now past, now-past.

Life isn't what you think.
Life isn't what will be in the future
for when that future has become now
it will be now and not the now we foresaw.
Life is what is before it becomes what was.

Life isn't what you think . . . or what I think . . .
or what ever it might be.
Life is.

Edna Foa on Prolonged Exposure Therapy

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Exposure Therapy Explained

Keith Sutton: Welcome, Dr. Foa. To get started, why don’t you tell us a little bit about what exposure therapy is. Many of our readers may be unfamiliar with, or may not remember much about, this type of therapy.
Edna Foa: Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them. The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur. Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction. In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

KS: Is that what’s called the flooding of the anxiety?
EF: Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.
KS: Yeah, common sense would make you think that, wouldn’t it?
EF: No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.
KS: One of the central ideas around the exposure is that the anxiety peaks within a reasonable amount of time and decreases. Is that right?
EF: Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."
KS: Is that the exposure hierarchy?
EF: Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.I always give the example of a person that is afraid of big dogs, but not of small dogs. The therapist decides to treat him by exposure to dogs, and brings to the session a small dog. Well, because the patient is not afraid of small dogs, this exposure will not work. Exposure needs to include the things that the patient is afraid of. The therapist then brings a big dog to the therapy session to do exposure. The patient enters the room, sees the dog, and gets very fearful. With the encouragement of the therapist, the patient slowly approaches the dog, which the therapist holds on a leash. When the patient gets close to the dog, the dog jumps on him and bites him. This is again not a successful exposure, because what does the person learn from it? He learns that he was right all along, that big dogs are dangerous.
KS: It reinforces that belief.
EF: Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.

Getting Off to a Powerful Start in Couples Therapy

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I am pleased to offer you this lesson from my online couples therapy training program. It has been adapted from a lecture, and includes commentary from Michelle, our moderator, as well as comments from the audience. This will give you a glimpse into some of my principles for “Getting Off to a Strong Start” in Couples Therapy.

In this article, we’re going to focus on the following points:
  • Getting Off to a Strong Start
  • Three Types of Goals and Effective Goal Setting Questions
  • Six Essential Elements of Early Interviews
  • Developmental Change vs. Behavioral Change
  • Identifying Vulnerable Feelings
Speaking of “strong starts,” let’s get going on our lesson…

Getting Off to a Strong Start

Ellyn: Today, we’re going to talk about getting off to a very strong and powerful start in couples therapy. And I’m going to teach you principles that have to do with both your mental set, so how you think about what you’re doing in those early sessions and how you position yourself with clients; and I’ll also be teaching some specific how-to’s. But this is not a cookie-cutter approach.
 
You will be looking at integrating pieces of this in the way that works for you, and also integrating pieces in terms of what is best for the kind of couple that you’re working with. I’ll highlight some of the pieces that work better with some couples and some that work better with other types of couples.
 
First, getting off to a strong and powerful start means you being a leader. By the time you’re finished with this course, “I want you to feel like you are a leader—that you are active in your work, you’re not reactive, and that right from the beginning you’re getting the couple’s attention.”
 
You’re establishing yourself as somebody who is strong, and somebody who understands and is able to help them. Also, they’ll know that they’re going to do the work and that coming to therapy is not waiting for you to wave a magic wand. If they will do the work, there is hope they can get out of the conundrum that they’re presenting to you.
 
The tone that you set from the very beginning is crucial and is based on the answers to the following questions: Do you see pathology? Are you looking for pathology or are you looking for developmental stuck places?
 
Seeing impasses as developmental stuck spots will help you and your couple be more optimistic. You’ll be able to inspire them that they, in fact, can overcome and can get out of their negative cycles.
 
Your style and what you pay attention to will indeed determine the direction of the therapy. I am always thinking, “How do I challenge my clients to develop themselves and to look at the development of themselves as something that is positive, that’s exciting, that can be rewarding and not something that’s a drudge or way too difficult for them to do?”
 
There are predictable reasons for why relationships fail. The primary issues that most couples struggle with are:
  • There is a lack of development in either or both of the individual partners.
  • They have a repetitive history of re-triggering emotional trauma in each other and not repairing it.
  • They don’t have the ability to repair when they hurt or do damage to one another.
  • They lack skills or knowledge.
Couples often don’t understand why they are struggling. They think that there’s something wrong with them or something is inherently flawed about their relationship. When you are thinking about the couple in front of you, the goals that you are going to set fall in one of three main arenas:
  • The couple is coming to you for change, growth and development.
  • They are coming to dissolve the relationship, to be able, in fact, to say goodbye to one another, to go through a divorce or separation, to get help with the kids and the parenting and in the process of separation to resolve any resentment so it doesn’t fester and impair their future relationship or their parenting.
  • They need help making a decision. A common one is, “Should we stay together or separate?” Maybe one wants to have a child and the other one doesn’t, or there’s some kind of move or job promotion situation that’s creating enormous difficulty about whether they’re going to stay where they are or move. And of course, there is, “Shall we get married or shouldn’t we get married?”
You can slot each of your couples into one of these three areas as you begin to think about goals that make sense for them.

An effective couples therapist will, over time, become both decisive and incisive and be able to sustain positive momentum. So when the couple starts backtracking, or when they start getting bogged down, those are times that you want to intervene and intervene quickly so that you can keep the momentum moving forward in a positive way.
 
It is absolutely essential that you not get stuck in their negative cycles or allow their negative patterns to go on for a long time in front of you. You only need to see it briefly so you understand what they do.
 
Michelle: At that point, Ellyn might you point out the cycle that you’re seeing and explain it back to them?
 
Ellyn: Yes, I will point it out, because having a grip on the negative cycle is the beginning to disrupting it. It’s the first step of changing it. So as long as you’re sure that you’re not doing it in a negative, judgmental or critical way, pointing out their negative cycle can always be an effective intervention. What we’re going to look at a lot is the essential elements of early sessions and the whole process of goal setting.
 
Too many couples ignore their shortcomings and do not seek help until it is too late. Therefore you have people very often coming in to see you when they think it’s too late, when you might wonder if it’s too late—and indeed, sometimes it is too late. But the patterns have been going on a long time, and that’s why getting their attention and assessing with them whether they’re there to dig in and do the work is important. If the couple is ready to dig in and do the work, one of the things you want to ask yourself is do you have the time to see them? Do you have the time to work with them?
 
When I do a first session, I never do it shorter than a double session. It’s almost impossible to assess a couple, in my opinion, in a 50-minute hour. You’re talking about assessing two individuals and the relationship. Most of us would never spend just 25 minutes assessing an individual client, so I’m always asking people to come for a double session to begin with.
 
Usually when I’m getting started with a couple I want to see them frequently. I want to see them for a minimum of two-hour sessions, and this is especially true for those that are disorganized, hostile, fighting or on the verge of splitting up. It’s not a good idea to accept a couple who is in a bad situation if you’re not going to be able to make time for them in your schedule.
 

Essential Elements of Early Interviews

  • Make contact with each partner
  • Understand the problem
  • Name feelings being experienced
  • Empathically embellish those feelings
  • Describe the destructive cycle, but…
  • Set a clear direction… a way out (including delineating the importance of containment, repair and autonomous change)
  • Define your role and your expectations for them
These essential elements are spread out through the first couple of sessions. The first essential element is making positive contact with each partner. That is, establishing the relationship and being able to understand the problem from each partner’s perspective. Sometimes it takes more work to understand it from one partner’s perspective than the other.
 
As you’re listening, name feelings that you’re hearing that are being experienced. Be able to empathically embellish them, to describe the destructive cycle and point out a clear direction for change. Delineate the importance of each partner containing their reactivity. Another part of the early sessions is defining your role and expectations for them as clients.
 
Making contact is something every therapist learns in psychology or counseling 101. One way to assess how hard it’s going to be to make contact is to ask your clients when they first come in, “How do you feel about being here even though we haven’t done anything yet?”
 
Their responses to that question will let you know who’s going to be easy and who’s going to be difficult to connect with. It’s a common situation for one member of the couple to say, “I’m so relieved. I thought we would never get here. I’ve wanted to come for a really long time. I’m glad we’re here,” and for another member of the couple to say something like, “I don’t believe in therapy. I didn’t want to come and I think this is just a waste of time.” It’s pretty obvious who’s going to be the harder partner to make contact with!
 
Other aspects of making contact include:
  • Being friendly, kind and interested.
  • Appreciating their anxiety. Couples therapy is more unpredictable than individual therapy.
  • Acknowledging lack of control over what the other partner says or does.
  • Hearing their story in the context of the structure you provide.
  • Giving lots of positive strokes can be highly valuable in the early sessions.
Particularly, I like to highlight areas where I see a partner taking a risk, where I see them making themselves vulnerable and where they’re stretching themselves. I will do a lot of positive stroking of those aspects rather than focusing on anything that I think is contributing to their cycle. I also think it’s helpful to appreciate their anxiety. “Couples therapy is harder in many ways for partners to come to than individual therapy. They think to themselves, “It’s unpredictable what my partner is going to say about me.”” In individual therapy we have complete control over that, but in couples therapy they’re often anxious about what’s going to be revealed.
 
Another thing I would let the couple know is that I will provide a safe structure and context for them to tell me their story. So if the partner keeps interrupting or keeps saying, “No, it didn’t happen that way,” I’ll say, “Wait, stop. I want to hear the story from each of your perspectives.” I want to get the whole picture and not let them be interrupted by the other one.
 
Michelle: Can you say a little bit about the beginning of the session when you ask them the question, “How do you both feel about being here?” and one person seems motivated and the other one not? Can you tell me what you do with that information? Do you orient the sessions differently?
 
Ellyn: Yes. When one person says they’re motivated and the other person says they’re not, I know it’s going to be essential for me to make contact with the partner who’s not motivated. I’m going to be especially observant about how I make a connection with that partner.
 
“Sometimes making that connection might be as simple as saying, “I’m glad that you came in today. Do you know that you can come to couples therapy and not have to change anything about yourself?”” Because they are so afraid that the focus is going to be on them and that they are going to be required to change. You will always have better buy-in for homework with the motivated client. So I am less likely to give the unmotivated client homework until I have a stronger connection with them.
 
I’m working to understand the couple’s problem both cognitively and affectively. The problem that they are bringing to me is usually understandable based on a couple of things: It’s understandable and predictable based on the attachment style of each partner. It’s also predictable based on the developmental stage. For example, if the couple has been together more than two years and they’re still stuck at the symbiotic stage, that’s going to be a problem, and that’s going to require them to be able to work in the area of differentiation.
 
The problems that they’re coming to you with will be a function of their arrested development—and once you have a full understanding of our Developmental Model of Couples Therapy, you’ll be able to describe that to them. It’s also predictable based on how long the partners have been together. A couple that’s been together just six months is not going to have any effective differentiation and I can’t possibly expect that they would.
 
On the other hand, with a couple who’s been together for 10 years, has a chronic history of conflict avoidance and has never differentiated, I know that it’s going to take a lot of risk, push and challenge for them to get out of that if they’re going to change the core dynamic of their relationship. Part of understanding the problem is asking helpful, insightful questions. In that process I want them to begin to think more deeply about what they’re saying. I also want them to understand the problem from an emotional or affective standpoint, so I’m going to be feeding back a lot of their feelings as well.
 
Here is an example of how you might describe a destructive cycle. I made it a little more complex than you might with most couples just to put a variety of both feelings and behaviors into it. I might say to Sally, “When you feel hurt by something that Ted says, it’s difficult for you to tell him that you’re hurt or to request an apology. Instead, when you feel hurt, a part of you wants to hurt him back so you tend to criticize him.”
 
Then to Ted I might say, “When you feel criticized by Sally, your tendency is to disengage and withdraw. Sally then ends up feeling lonelier, and instead of the two of you being able to repair and reconnect, the cycle keeps escalating. It keeps repeating and each of you is left in pain.”
 
Then I might ask them how they’re responding to what I’ve just said. And I look for their non-verbal cues, as well, to see if they agree with me. Are they connecting with what I’m saying, and does it make sense to them? Then you are able to not only connect with their feelings, but empathically embellish on them even more. The more you empathically embellish on your clients’ feelings, the more understood they’re going to feel, and the more able you’re going to be to confront that partner later on.
 
I want to have those moments of good empathic connection early on. Those might come from commenting on their deep loneliness or their helplessness, or you might say to a client, “You have tried and tried. You’ve tried everything and you’ve been really stuck, because nothing at all is changing. In fact, it looks to me like at this point you’re beside yourself with frustration and you wonder if there’s even a way out.”
 
A lot of people will nod their heads or begin to cry. They really know that you know how hard it has been for them, because they have been trying. And they didn’t know what to do. They didn’t know how to get out of that stuck position. So they might feel like you get and understands them.
 

Goal Setting

Michelle: A lot of couples at that point will also say, “Yes, you’ve got it.” Their anxiety will come up and they’ll say, “Okay, so what do we do about it?” And they’ll want to move fast at that point.
 
Ellyn: Right. And because they want to move fast, that can actually be a good bridge to goal setting. It’s not enough to be understood. I know that it is going to take change on the part of each person to change the dynamics between them. So I’m going to spend some time now talking to you about goal setting.
 
When you hear the words “set goals,” it’s so prevalent in our culture that it sounds like it should be something easy to do. And yet “to do good goal setting with couples is an incredibly sophisticated and complex skill that takes time.” It’s usually integrated into several sessions. It’s not something you can do in just one session unless you have an incredibly insightful couple who’s been in therapy before and they know what they want to do.
 
The more disorganized the couple is or the more hostility there is, the more challenging it’s going to be for you to arrive at effective goals. And I want you to come away from this lesson actually being able to reflect on the couples that you’re seeing and really ask yourself, “In which of these cases do I have strong goals that make sense and that will help move this couple forward?”
 
If your answer to yourself is, “I don’t” for any particular couple, then you can back up and say, “This is a good time to reassess. Let’s see what we can look at as the next goals to undertake.” One of my favorite cartoons is of two couples talking in one couple’s living room. One says to the other, “The work being done on your marriage… are you having it done or are you doing it yourselves?”
 
The reason I love this cartoon is because so many couples wish that the work would be done for them. They come in either hoping that you have a magic wand that you’ll wave to change their partner or that they can sit back, wait and watch for their partner to change.
 
That’s why the skill of getting each person invested in changing something about themselves that will move the relationship forward means that you’re dealing usually with character issues in each partner. You’re also dealing with motivation issues and possible resistance to therapy issues.
 
What is an effective goal? To me an effective goal is one that requires an individual to do some self-reflection and self-confrontation. And you’re asking the couple about their values and you’re implying that a change is needed in their pattern of reactivity. You’re asking them to self-select some new standard of behavior and to hold themselves accountable to whatever the change is that they are working on.
 
One way to think of the change needed in their reactivity is to think about what this person needs to stop doing in order to create the space for change to occur. You might think about it in terms of what this partner needs to start doing, or what both of them need to do differently that would enable them to take risks and move themselves forward.
 
Michelle: Ellyn, do you ever explain to your couples the concept of making a shift within themselves? I think that’s counter-intuitive to most couples when they come in, because they believe the problem is with their partner.
 
Ellyn: Yes, I do, and one of the things I talk about with some couples is the principle of autonomous change. What I mean is, not saying, “I will only change if you change,” which is a common thing that partners do—they tie their changes to whatever the other person does. I tell them, "If you make changes regardless of what your partner does, you will be able to have a very rich learning opportunity, because as you make changes, you’re going to see what unfolds; you may be very pleasantly surprised by the changes that start to occur, or you may find that your partner does nothing." Saying something like that is actually directed at both partners, including the partner who may be inclined to do nothing because they’ll realize that it’s going to be observed if they, in fact, are doing nothing.
 
A good solid goal will be clear and it will contain action and behavior. You and I know some about the intrapsychic change that’s behind any particular behavior, but by putting it in behavioral terms for them it becomes concrete and somewhat measurable.
 
When you’re looking for these changes in behaviors and actions, you’re also looking at whether the person has a real motivation to accomplish them. If there’s no motivation to change, it’s a useless goal and not one that I want to accept.
 
If somebody says to me, “I should pick up more clutter. I should pick up after myself,” I might say back to them, “I wonder how badly you really want to do that. Is that something you want for yourself or something that you think somebody else is telling you that you should do?”
 
Usually they’ll say, “I’m getting so much criticism from my partner that of course I think I should do it.”
 
And I might say back to them, “I wonder how picking up would be helpful to you. Is there anything that you can see that would motivate you to begin to pick up more?”
 
That can go into a 20- or 30-minute conversation until you get the piece of motivation that would genuinely be motivating for that partner to start to clean up more clutter. You’re always looking for goals that are individually focused, not dependent on what the other person does. The goals can be contradictory, and by that I mean even as extreme as one partner saying, “I’m here to get help with ending this marriage and I’d like to do some of the steps that are involved to end this marriage in a good way.” The other person might say, “I’m here to build a positive marriage and I do not want this marriage to end.”
 
Even though these are such contradictory directions that will create anxiety in the room, they are genuine for each partner. And then you can figure out what that literally means for each of them to be able to carry those goals out. Always remember that knowing the presenting problem is not a goal. Typically, couples will say things like, “We have a communication problem and we need to communicate better.” Nothing about that is a goal.
 
“Don’t assume you have goals and objectives when you know the presenting problem.” When you ask most couples why they are there, the typical response is a description of their partner’s failures, shortcomings and things they do badly. They want to get relief by having their partner make the necessary changes. It’s very rare for them to describe to you what they need to do in order to strengthen the relationship.
 

Homework Assignments

Over the years I’ve challenged myself to come up with lots of different ways of setting goals with couples. I’ve used lots of different kinds of questionnaires, and I’m encouraging you all to experiment with what works for you in your practice and what works with different kinds of clients.
 
One very simple form instructs them over the week to go home and answer the following five questions:
 
What type of relationship do you want to create? I give them examples to help get them started: “You might say you want to create a loving intimate relationship, a relationship with a lot of team work. You might say you want a more companionate relationship.”
 
How do you want to be as a partner? This is asking for a frank self-assessment. How do they in fact want to be? Do they want to be somebody who makes time for the relationship, somebody who wants to negotiate solutions that are working for both people? How do they want to be in their day-in-and-day-out life?
 
What do you want to learn about yourself or the relationship? This is a request for cognitive knowledge that each partner would like to obtain. An example would be understanding your patterns as a reflection of some early childhood experiences.
 
What do you want to stop doing? Common examples are blaming, name-calling, withdrawing, or avoiding conflict.
 
What do you want to start doing instead? In evaluating responses to this question you are looking for constructive behavior that each partner will do when they stop doing the behavior that is contributing to the negative cycle.
 
Before I have people take it home and fill it out, I give them some examples of answers. A lot of times people will say things like, “I want to stop blaming and criticizing. I want to start giving my partner more positive strokes. I want to start saying what I appreciate and I want to start looking for more win-win resolutions.”
 
I ask them not to share their answers with each other until they come back the following session. Then I have them read their responses to each other and we work at refining what makes sense as a goal. You can also use this form to assess their progress as you go through the next few weeks.
 
Here’s another questionnaire I sometimes give couples as homework:
  • What do I want to learn or understand?
  • What do I want to stop doing? 
  • What do I want to start doing differently to build a more loving, giving relationship? 
  • What is most urgent for me?
One couple, Cindy and Jack, answered these questions. When they came back here’s what they had written:
 
Jack said, “I want to learn where my blind spots are that come from my family of origin. I want to stop withdrawing, and start being less defensive. It’s urgent that I be more able to do what I want to do.”
 
Cindy came back and said, “I want to learn about where I get stuck in loving my husband. I want to stop being like his mother and accept that I am his equal. It’s urgent that the abundance in our relationship continue.”

What do you think is wrong with these goals?
 
Participant: I think that neither one of them actually said something concrete about what they could do. They talk about what they want to happen, but they aren’t coming up with anything concrete that they could do.
 
Ellyn: That’s right.
 
Participant: “Learning my blind spot” might be necessary to understand and to stop withdrawing, but under what circumstances or how would he do that?
 
Ellyn: That’s right. There’s nothing concrete here; it’s vague. You don’t get a sense of what they’re going to do. With Cindy we don’t have any idea of how she might be like his mother and why it would be important for her to stop being like his mother. “When you ask the question about what’s most urgent, urgent usually has a timeline, not something so open-ended as wishing for “the abundance in our relationship to continue.””
 
For Jack, you can’t picture what he really means by being less defensive. And when he said that it’s more urgent that he be able to do what he wants to do, I wanted to know what kinds of things he wants to do. When I pursued that with Jack, he felt like it was completely impossible to spend any of his non-work time away from Cindy. When we began to define it further, one of the things that was urgent for Jack was to have the ability to have some individual time alone each week. And then it went even further that he wanted to be able to take some golf lessons. So we were getting into something that could disrupt the intensity of this enmeshed, conflict-avoiding couple.
 
Next Cindy started to refine her goals and it shifted to, “I want to understand why I feel depressed when Jack and I disagree. I want to stop walking out of the room when we have a disagreement. I’d like to learn how to talk through a conflict from beginning to end, and be willing to listen to Jack’s side. And it’s urgent that I stop catastrophizing conflict to mean that the marriage is over.” She was a very conflict-avoiding partner who was fearful. She would become extremely anxious at any moment there was conflict and because she would get so anxious she would leave, disengage, or get out so that the conflict couldn’t surface. She was terrified that conflict would end the marriage.
 
I talk about the principle of character a lot with couples: when you’re in a committed partnership, it tests your character. It tests your character in a way that most other relationships don’t test your character. It’s easy to be nice, warm and loving when you fall in love with somebody. And it’s easy to be nice, kind and loving when everything is going right. But when your partner acts like a human being, do you get indignant?
 
Do you get incensed that your partner is human and has normal flaws? Can you accept that maybe your partner gets a little anxious and testy if they think you’re going to be late for an airplane? Or if they’ve had two or three cranky kids all day long and feel spent, when you walk in the door and they don’t say “hello” to you in the best possible way, can you give them a break? Can you be forgiving?
 

The Three-Circle Exercise

To finish up this lesson, I am going to give you one more concrete way to set goals. At the end of the article, you will find a diagram with three circles, called “Uncovering Vulnerability and Shifting Negative Patterns.” This three-circle exercise is a way to establish more effective goals.
 
I ask partners, “When you are at your worst, how do you act with each other?” Sometimes I’ll even brainstorm a list and put it on a white board that I have in my office. We’ll create a little list of things like “get critical, blame, yell and break things.” Encourage them to tell you what they do when they’re at their worst. I choose four of the items in this list and write them in the circle diagram.
 
The next part is tricky. “Ask them to tell you the emotion that is hardest for them to show to their partner when they’re at their worst. When they’re at their worst the way that they act is covering a more vulnerable feeling.” In this particular case one client said, “When I puff up and get grandiose I’m covering up fear.” We worked to get to that. “When I break possessions I tend to be hiding the fact that I feel a lot of shame. When I scream and escalate it’s usually covering up the fact that I feel inadequate and helpless. When I yell, I don’t want my partner to see that I’m feeling very vulnerable or fearful.” Write four of their answers in the second circle diagram.
 
Then circle number three is designed for what they want to do instead of these things. When they’re at their worst, what do they want to shift that will make a definite change in the relationship? And here what that client said was, “What I want to do instead is I want to say that I’m frightened, be able to admit that I did something that may have been stupid and unthinking, and know that that’s just human. I also want to be able to take deep breaths and be able to take a timeout.” And the last one was, “I want to be able to say ‘I don’t know how to help you now,’ to my wife.”
 
I sometimes ask clients to take these diagrams home and post them somewhere that feels comfortable: somewhere they can look at them and refer to them. It gives you a wonderful tool when they come back and they’re talking about having had a difficult fight or difficult interaction. You can ask, “Where does it fit on here? Were you able to stretch at all? Were you able to do something new? Were you able to take a risk? Were you able to show your fear? Were you able to show that you felt vulnerable?” This is a powerful way to set some effective goals.
 

Conclusion

One way to know if your goals are effective is to see if the partners begin to grow and change. Over time they’ll assume new roles with each other, new responsibilities, and new ways of being. And the relationship will begin to move through its stages of development and become increasingly more interdependent.
 
I want you to ask yourselves, “Is there noticeable change in the couples and partners I’m working with or are they just spinning their wheels?” If they are spinning their wheels I would say it’s time to go back and reset goals with them. Couples work is one of the most rewarding, wonderful things you can do with your time and it will always challenge you to stretch and grow. It is not for the faint of heart.
 
If you would like to learn more about the couples therapy training program from which this lesson was excerpted, please go to http://www.couplesinstitutetraining.com/developmentalmodel. Or if you’d like to read a handout to prepare your couples for being in couples therapy please go to http://www.couplesinstitute.com/freehandout.